TX HHS Form 3052. Practitioner's Statement of Medical Need

Form 3052, titled Practitioner’s Statement of Medical Need, is a required medical certification used in Texas Medicaid Personal Attendant Services programs, specifically Primary Home Care (PHC) and Community Attendant Services (CAS). The form documents that a person has a qualifying medical condition and related functional limitations that justify the need for non-skilled attendant services in the home.

Purpose of Form 3052

The purpose of Form 3052 is to provide formal medical confirmation that an individual meets the eligibility criteria for PHC or CAS services. Texas Health and Human Services Commission (HHSC) relies on this form to determine whether Medicaid-funded attendant services are medically necessary and appropriate.

Without a properly completed and signed Form 3052, HHSC cannot authorize personal attendant services, and service initiation may be delayed or denied.

When This Form Must Be Submitted

Form 3052 is required in the following situations:

• Initial application for PHC or CAS services
• Reauthorization of services when medical need is reviewed
• Changes in medical condition that affect functional limitations

The form is not required for Medicare home health services, Medicaid waiver programs, or skilled nursing services. It applies only to non-skilled personal attendant services administered by HHSC.

Who Is Authorized to Complete the Form

Different sections of Form 3052 must be completed by different parties:

• The Home and Community Support Services Agency (HCSSA) or employer completes the individual and provider information.
• The HCSSA or Financial Management Services Agency (FMSA) certifies practitioner eligibility.
• A licensed medical practitioner completes and signs the medical certification.

The practitioner must be a licensed physician (MD or DO), physician assistant (PA), or advanced practice nurse (APN) and cannot have a financial ownership interest in the service provider.

Explanation of Each Key Section

Part I – Person’s Information

This section identifies the individual requesting services and the HCSSA or employer responsible for coordinating care. Accurate identification is essential for matching the form to the correct Medicaid record.

Part II – HCSSA or FMSA Certification

The provider certifies that the practitioner is not excluded from participation in Medicare or Medicaid programs. This safeguard helps ensure program integrity and compliance with federal and state oversight requirements.

Part III – Practitioner’s Statement and Functional Limitations

The practitioner confirms that the individual has at least one functional limitation related to a medical diagnosis. The checklist includes limitations such as mobility issues, cognitive impairment, incontinence, vision or hearing loss, and other conditions affecting daily living.

At least one qualifying functional limitation must be selected for eligibility.

Part IV – Medical Diagnoses and Certification

This section documents the medical diagnosis or diagnoses supporting the need for services. The practitioner must certify that the individual was evaluated within the last 12 months or that they have ongoing knowledge of the individual’s medical condition.

The form clearly states that a diagnosis of mental illness or intellectual disability alone does not qualify as medical need without another medical diagnosis.

Practitioner Signature and Credentials

The practitioner must sign and date the form, include license and NPI numbers, and provide contact information. Unsigned or undated forms are not valid.

Practical Tips for Completing Form 3052

• Ensure the medical evaluation is current within the last 12 months.
• Select all applicable functional limitations tied to the diagnosis.
• Avoid adding an end date unless the condition is truly temporary.
• Confirm the practitioner has no ownership interest in the provider.
• Submit the completed form before requesting HHSC authorization.

Common Mistakes to Avoid

• Missing practitioner signature or date
• Listing only mental health diagnoses without a medical condition
• Including unnecessary end dates for ongoing conditions
• Using an ineligible or excluded practitioner
• Submitting the form after services are requested

Legal and Regulatory Context

Form 3052 is required under Texas Medicaid rules governing PHC and CAS services. HHSC regulations require documented medical necessity to ensure services are provided only to eligible individuals and to prevent inappropriate use of Medicaid funds.

The form becomes part of the individual’s official Medicaid record, and inaccurate or incomplete information may result in service denial, termination, or recoupment.

Real-Life Situations Where This Form Is Used

• An older adult with mobility limitations applies for in-home attendant assistance.
• A person with chronic illness needs help with bathing and meal preparation.
• An individual transitioning out of a hospital requires non-skilled daily support.
• A temporary medical condition limits a person’s ability to perform daily tasks.

Documents Commonly Submitted with This Form

• Medicaid eligibility documentation
• HCSSA service enrollment forms
• Medical records supporting diagnosis
• Service authorization requests

Frequently Asked Questions

Is Form 3052 required for all PHC and CAS applicants?

Yes, a completed practitioner statement is mandatory for authorization.

Can services start before the form is signed?

No, services require prior medical certification.

Does mental illness alone qualify?

No, there must be a qualifying medical diagnosis.

How recent must the medical evaluation be?

Within the past 12 months.

Who reviews this form?

HHSC regional nursing staff review it for authorization.

Can an end date cause service termination?

Yes, unnecessary end dates may stop services.

Related Forms

• Service Authorization Request Forms
• Medicaid Eligibility Verification Forms
• Financial Management Services Agreements
• Personal Attendant Service Plans

Form Details

• Form Name: Practitioner’s Statement of Medical Need
• Form Number: 3052
• Programs: Primary Home Care (PHC), Community Attendant Services (CAS)
• Issued By: Texas Health and Human Services Commission
• State: Texas
• Revision Date: May 2022