TX HHS Form 3057. Kidney Health Care Program Physician Assessment

The TX HHS Form 3057, Kidney Health Care Program Physician Assessment, is a crucial document that helps solve the problem of verifying an applicant's medical information for the Kidney Health Care Program. This form is used in situations where a signed and dated copy of the CMS 2728 form is not available.

This physician assessment form requires key information about the applicant's medical history, including their current treatment, start dates, and facility details. The form also asks the physician to provide their contact information, including area code and phone number, as well as a National Provider Identifier (NPI) number. By completing this form, physicians acknowledge that they are stating from their personal knowledge that the facts on the form are true and correct.

The Kidney Health Care Program Physician Assessment is typically filled out by the applicant's physician and returned to the social worker, who will submit it along with the application to the program. This form plays a critical role in ensuring that applicants receive the necessary care and support for their kidney health. Some key points to note include:

• This form is used when a signed and dated copy of the CMS 2728 form is not available.
• The form requires information about the applicant's current treatment, start dates, and facility details.
• The physician must provide their contact information, including area code and phone number, as well as a National Provider Identifier (NPI) number.