TX HHS Form 3074. Physician Certification of Terminal Illness

The TX HHS Form 3074, Physician Certification of Terminal Illness, is a crucial document that helps verify an individual's terminal condition for Medicaid or Medicare hospice coverage. This form must be completed by the individual's physician(s) to certify their terminal illness with a medical prognosis of six months or less to live if the illness runs its normal course.

The form requires the following information: the hospice provider's name, contract number, and address; the individual's name, HHSC Medicaid number, Medicare number, and social security number; and the election or start date. The physician(s) must also sign and date the certification statement, which includes a verification that the individual is terminally ill with a medical prognosis of six months or less to live.

This form should be used when an individual elects Medicaid or Medicare hospice coverage and their terminal condition needs to be verified within two days of the election date. The form must be completed by the physician(s) and submitted to the relevant authorities to ensure payment for hospice services. Note that oral verification from a physician licensed in the state of Texas or on duty with the U.S. military is also acceptable, as long as it is entered into the individual's hospice record within the initial 90-day election period.