TX HHS Form 3071. Individual Election. Cancellation or Update
Form 3071 is an official enrollment and authorization document used in the Texas Medicaid Hospice Program. The form allows an individual, or their authorized representative, to formally elect hospice services, update existing hospice information, or cancel participation in the Medicaid hospice benefit.
This document is a key part of ensuring that hospice services are delivered appropriately, that benefits are coordinated with Medicare when applicable, and that Medicaid coverage rules are followed.
Purpose of Form 3071
The primary purpose of Form 3071 is to document a person’s informed decision regarding hospice care under Texas Medicaid. It records whether hospice services are being elected, updated, or canceled and confirms that the individual understands how hospice enrollment affects other Medicaid-covered services.
The form is required to:
- Authorize Medicaid hospice services
- Document election or cancellation of hospice care
- Coordinate benefits between Medicaid and Medicare
- Confirm informed consent regarding waived services
When This Form Must Be Used
Form 3071 is required in the following situations:
- When an individual elects Medicaid hospice services for the first time
- When hospice information must be updated, such as provider or setting changes
- When an individual chooses to cancel Medicaid hospice services
The form is generally not required for non-hospice Medicaid services or for individuals who have not elected hospice care.
Who May Complete and Sign the Form
The form may be completed by the hospice provider but must reflect the decision of the individual receiving services. Signatures typically involve:
- The individual receiving hospice care
- A legally authorized representative (if applicable)
- A hospice program representative
The attending physician’s information and orders are also required to support hospice eligibility.
Explanation of Each Key Section
Form Type and Dates
This section identifies whether the form is being used for an election, update, or cancellation and specifies the effective date range. Selecting the correct form type is essential to avoid coverage gaps.
Care Setting and Coverage Indicators
The form records where hospice services will be provided, such as the individual’s home, nursing facility, hospital, or inpatient hospice unit. It also documents whether the individual has Medicare Part A, which affects coordination of benefits.
Individual Identification
This section includes the individual’s name, Medicaid number, Social Security number, date of birth, county, and current location. Accurate identification ensures proper billing and eligibility verification.
Terminal Diagnosis Information
All terminal diagnoses must be listed using appropriate ICD codes. This information supports medical necessity and hospice eligibility.
Provider and Hospice Information
This section identifies the hospice provider, contract number, contact information, and attending physician details, including state license number and date of orders.
Individual’s Declaration
This section confirms that the individual understands the nature of hospice care, the difference between palliative and curative treatment, and which Medicaid services are waived. It also explains the individual’s right to cancel and re-elect hospice services at any time.
Signatures and Dates
The printed name and signature of the hospice representative and the applicable dates finalize the election, update, or cancellation.
Practical Tips for Completing Form 3071
- Verify Medicaid and Medicare coverage before selecting the form type.
- Ensure all terminal diagnoses are listed and coded correctly.
- Confirm the care setting matches where services will be delivered.
- Double-check effective dates to avoid service interruptions.
- Keep a copy of the completed form for personal and provider records.
Common Mistakes to Avoid
- Using the wrong form type (election vs. update vs. cancellation)
- Leaving diagnosis fields incomplete
- Incorrect or missing Medicaid or Social Security numbers
- Failing to coordinate Medicare and Medicaid hospice elections
- Missing required signatures or dates
Legal and Regulatory Context
Form 3071 is required under Texas Medicaid hospice program rules, which are aligned with federal Medicaid and Medicare hospice regulations. State and federal law require documented informed consent when hospice services are elected, including acknowledgment of waived services and the individual’s right to revoke hospice at any time.
Failure to properly complete this form may result in denied claims or gaps in hospice coverage.
Real-Life Situations Where This Form Is Used
- An individual with a terminal illness elects Medicaid hospice care for the first time.
- A hospice patient moves from home care to an inpatient hospice unit.
- A patient decides to cancel hospice services to pursue curative treatment.
- Provider information changes and an update is required.
Documents Commonly Needed with This Form
- Physician certification of terminal illness
- Medicaid eligibility documentation
- Medicare coverage information
- Hospice provider enrollment records
Frequently Asked Questions
Can hospice services be canceled at any time?
Yes, individuals may cancel and later re-elect hospice services without penalties.
Does hospice election affect all Medicaid services?
No, only Medicaid services related to the terminal illness are waived.
Is Medicare enrollment required?
When eligible for both programs, Medicare and Medicaid hospice must be elected together.
Who signs the election?
The individual or their legally authorized representative.
What happens if information changes?
An update form must be submitted to reflect the change.
Related Forms
- Physician Certification of Terminal Illness
- Hospice Provider Enrollment Forms
- Medicaid Eligibility Forms
- Medicare Hospice Election Forms
Form Details
- Form Name: Individual Election, Cancellation, or Update
- Form Number: 3071
- Program: Texas Medicaid Hospice Program
- State: Texas
- Revision Date: February 2023