TX HHS Form 3074. Physician Certification of Terminal Illness

Form 3074, titled Physician Certification of Terminal Illness, is an official Texas Health and Human Services Commission (HHSC) document used within the Texas Medicaid Hospice Program. This form confirms that an individual meets the medical eligibility requirements for hospice care by documenting a physician’s professional determination that the individual has a terminal illness with a life expectancy of six months or less, if the illness follows its normal course.

The form is a mandatory component for initiating or continuing Medicaid or Medicare hospice coverage in Texas. Without a properly completed and timely signed Form 3074, hospice services may not be reimbursed.

Purpose of the Form

The primary purpose of Form 3074 is to establish medical eligibility for hospice services under Texas Medicaid and Medicare rules. It serves as formal evidence that the individual’s terminal condition has been evaluated and certified by licensed physicians within strict regulatory timeframes.

This form is required both for the initial hospice election and for subsequent recertifications during ongoing hospice care.

Who Must Complete This Form

Form 3074 is completed by licensed physicians and hospice providers involved in the care of a terminally ill individual. It is not filled out by the patient or their family.

• The attending physician (if one exists)
• The hospice physician
• Hospice administrative staff responsible for compliance and billing

When the Form Is Required — and When It Is Not

This form must be completed:

• At the start of Medicaid or Medicare hospice coverage
• Within two days of the hospice election or start date
• For each required recertification period during hospice care

The form is not required for individuals who are not seeking hospice benefits or whose care is outside the Texas Medicaid Hospice Program.

Regulatory and Legal Background

Form 3074 is governed by federal Medicare hospice regulations and Texas Medicaid hospice requirements administered by HHSC. These rules require physician verification of terminal illness to ensure hospice benefits are provided only to eligible individuals.

Failure to meet certification or timing requirements can result in denial of Medicaid or Medicare payment for hospice services prior to the certification date.

Section-by-Section Explanation

Provider and Individual Information (Items 1–11)

These sections identify the hospice provider, contract number, and the individual receiving care. Accurate identifiers such as Medicaid number, Medicare number, and Social Security number are essential to avoid claim rejections.

Election or Start Date (Item 9–10)

This section establishes whether the form is for an initial certification or a recertification and records the relevant date. This date is critical because certification must occur within two days of the hospice election.

Oral Verification

If written certification is not immediately available, the form allows documentation of oral verification obtained from a licensed Texas physician or a physician on U.S. military duty. This oral certification must later be signed and dated within the initial 90-day election period.

Physician Certification Statements

Both the hospice physician and the individual’s attending physician must certify the terminal illness, unless no separate attending physician exists. Each physician must provide their printed name, license number or military specification code, and signature date.

Exclusion Statement

If the individual does not have an attending physician separate from the hospice physician, a hospice staff member must complete and sign the exclusion statement.

Documents Commonly Attached

• Clinical records supporting the terminal diagnosis
• Physician progress notes
• Hospice election statements
• Internal hospice documentation of oral verification (if applicable)

Practical Tips for Completing Form 3074

• Verify all dates carefully to ensure compliance with the two-day rule.
• Confirm physician license numbers are current and legible.
• Do not delay written signatures when oral verification is used.
• Ensure both required physicians sign unless the exclusion statement applies.

Common Mistakes That Cause Payment Delays

• Missing physician signatures or dates
• Certification completed outside the allowed timeframe
• Incorrect Medicaid or Medicare identification numbers
• Failure to document oral verification properly

Real-Life Use Scenarios

• A hospice enrolls a Medicaid recipient and must certify terminal illness within two days to ensure coverage begins on time.
• A patient transitions from hospital care to hospice, requiring rapid oral verification followed by written certification.
• A hospice provider submits a recertification to continue coverage beyond the initial benefit period.

Frequently Asked Questions

Is Form 3074 required for both Medicaid and Medicare hospice care?

Yes. The form supports eligibility for both Medicaid and Medicare hospice coverage in Texas.

Can oral certification replace physician signatures?

Only temporarily. Oral verification must be documented and followed by signed written certification within the required timeframe.

How many physicians must sign the form?

Typically two physicians must sign unless the patient has no attending physician separate from the hospice physician.

What happens if certification is late?

Hospice payment will not be made for services provided before the certification date.

Who keeps the completed form?

The hospice provider maintains the form in the individual’s hospice record.

Micro-FAQ

• Purpose: Certifies terminal illness for hospice eligibility.
• Who files: Hospice and attending physicians.
• Deadline: Within two days of hospice election.
• Attachments: Clinical and diagnostic records.
• Submitted to: Maintained by the hospice provider for HHSC compliance.

Related Forms

• Hospice Election Statement
• Medicaid Hospice Claims Forms
• Physician Recertification of Terminal Illness

Form Details

• Form Name: Physician Certification of Terminal Illness
• Form Number: 3074
• Program: Texas Medicaid Hospice Program
• Issued By: Texas Health and Human Services Commission
• Revision Date: January 2023