TX HHS Form 3079. Facility Payment Rate Request

The TX HHS Form 3079, "Facility Payment Rate Request," is a crucial document for healthcare facilities seeking reimbursement from Texas Health and Human Services (HHS) under the County Indigent Health Care Program (CIHCP). This form helps facilities request payment rates for inpatient and outpatient services provided to indigent patients.

The form requires key information, including the facility's name, address, and 10-digit National Provider Identifier (NPI) number. Facilities must also specify the rate(s) requested, which can include inpatient and outpatient rates per visit. The form includes spaces for facilities to provide their area code and phone/fax numbers, as well as the date submitted to HHS.

This form should be used by healthcare facilities seeking reimbursement from HHS for services provided under the CIHCP. Facilities must complete this form in its entirety to ensure accurate and timely payment processing. The TX HHS Form 3079 is a vital tool for facilities looking to streamline their payment requests and receive fair compensation for their services.