TX HHS Form 3111. End-Stage Renal Disease Evaluation

The TX HHS Form 3111, End-Stage Renal Disease Evaluation, is a crucial tool for determining eligibility and developing rehabilitation plans for individuals with end-stage renal disease. This form helps healthcare professionals and counselors assess the patient's medical history, reported disability, and reason for referral to provide targeted support.

The form requires essential information such as the patient's date of birth, social security number, and telephone number. It also includes sections on medical history, etiology, and associated abnormalities. The etiology section allows users to select from various options including glomerulonephritis, diabetes mellitus, and lupus erythematosus, among others. Additionally, the form asks about reported disability and reason for referral, which helps counselors develop a personalized rehabilitation plan.

This form should be used when evaluating individuals with end-stage renal disease to determine their eligibility for rehabilitation services. The TX HHS Form 3111 is an essential tool for healthcare professionals and counselors working in the field of end-stage renal disease evaluation and rehabilitation planning. By completing this form, users can ensure that they are providing the necessary information to support a patient's rehabilitation journey.