TX HHS Form 3106. Comprehensive Rehabilitation Services Referral

The Comprehensive Rehabilitation Services Referral Form 3106 is a tool used by healthcare professionals to refer individuals in need of rehabilitation services. This form helps solve the problem of connecting patients with appropriate treatment options, ensuring they receive the necessary care to achieve optimal health outcomes.

This form requires key information about the individual being referred, including their name, contact details, and medical history. Important sections include the required diagnosis, anticipated discharge date, and funding sources. The form also asks if the individual is aware of the referral and what services Comprehensive Rehabilitation Services (CRS) provides. Common scenarios of use for this form include referrals from hospitals, nursing homes, or state agencies.

The form explicitly mentions conditions such as Traumatic Brain Injury (TBI), Traumatic Spinal Cord Injury (TSCI), and medically stable status. It also asks about the individual's language preference and whether they have a medical power of attorney (POA) or other POA. The form should be used when an individual requires rehabilitation services, and it is essential to complete the form in its entirety and attach all necessary supporting documentation before submitting.