Form 3074, Physician Certification of Terminal Illness
Effective Date: 9/2014
English PDF: 3074.pdf
Spanish PDF: 3074-S.pdf
To certify an individual—s terminal diagnosis and life expectancy of six months or less if the terminal illness runs its normal course, and to establish enrollment for the Medicaid hospice program.
Disclaimer: This is a Texas Medicaid Hospice form. Providers may choose to use this form for individuals eligible for Medicare; however to ensure accurate responses, Medicare hospice providers must contact the fiscal intermediary.
When to Prepare
- When an individual elects the Texas Medicaid Hospice program.
- If the hospice cannot obtain the written certification within two calendar days after the period begins, the provider must obtain an oral certification within two calendar days.
- The physician must complete, sign and date Form 3074 within each coinciding six month certification period.
- An individual is certified for subsequent six month certification periods after the first certification period.
- For recertification for hospice services that occurs every six months.
- The hospice physician must complete, sign and date a new Form 3074 within each six month certification period.
- When corrections are made to a previously submitted Form 3074.
- The physician must sign the initial certification no more than 15 days before the period begins, but not later than the expiration date of the initial certification. The physician must sign the recertification before the period begins but no more than 30 days prior to the begin date.
- The two-day grace period for verbal verification of terminal illness in the initial certification period does not apply to subsequent recertification periods.
- If the physician signs Form 3074 after the coinciding six month certification date, the effective date for Medicaid payment will be the date the document is signed by the physician. Medicaid will not pay for services prior to that date.
- If an individual is discharged from hospice services for any reason and is then readmitted to hospice services, regardless of the amount of time, a new Form 3074 must be completed.
Hospice providers are responsible for transmitting Form 3074 electronically on the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Online Portal. Hospice providers must send a copy of Form 3074 to the nursing facility (NF) or the intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), if applicable.
To set up an account to submit electronic forms, contact TMHP Electronic Data Interchange (EDI) at 1-800-626-4117, option 3.
To speak with TMHP customer service for assistance with navigating the TMHP LTC Online Portal, contact TMHP at 1-800-626-4117, option 1.Form Retention
Retain this form according to the record retention requirements in Title 40 Texas Administrative Code (TAC), Chapter 49, Contracting for Community Care Services.
The hospice provider must maintain an original signed and dated form in the individual—s hospice record.
- Hospice Provider Name — Enter the doing business as (DBA) name of the Medicaid hospice provider as it appears on the DADS Medicaid hospice contract.
- Contract No. — Enter the nine-digit Medicaid hospice provider contract number as it appears on the DADS Medicaid hospice contract.
- Provider Address — Enter the Medicaid hospice provider address as it appears on the DADS Medicaid hospice contract.
- Correction (check if applicable) — Mark the box when submitting a correction to a previously submitted Form 3074.
- Individual—s Name (Last, First, Middle) — Enter the individual—s name as it appears on the individual—s Your Texas Benefits (YTB) Medicaid card.
- DADS Medicaid No. — Enter the individual—s Medicaid number as it appears on the individual—s YTB Medicaid card. If the individual has applied for, but is not yet receiving Medicaid benefits, enter "Pending" in the Medicaid number field.
- Medicare No.— Enter the individual—s Medicare number, if applicable.
- Social Security No. — Enter the individual—s Social Security number.
- Election/Start Date — Enter the hospice election date (MMDDYYYY) Note: If the individual elects hospice on Jan. 1, 2014, and on June 30, 2014, the provider completes Form 3074 for recertification, the election date remains Jan. 1, 2014.
- Check Appropriate Box and Enter Date — Check the appropriate box and enter the current certification or recertification date (MMDDYYYY). For example, if the individual elects hospice on Jan. 1, 2014, and the certification date is Jan. 1, 2014, the physician(s) must sign the certification by June 30, 2014. If the recertification date begins July 1, 2014, then the physician must sign by Dec. 31, 2014.
- Individual—s Address — Enter the address where the individual receives hospice services.
- Signature — Hospice Staff — Hospice staff must sign the verbal verification when verbal verification is obtained from the physician within two days of the hospice election date.
- Date Signed — The hospice staff must enter the date (MMDDYYYY) the verbal verification statement is signed.
- Print Name of Attending Physician (Last, First) — Print the physician's name.
- Signature — Attending Physician —The attending physician must sign Form 3074 within the applicable certification/recertification time frame.
- Check Appropriate Box and Enter Number —The physician must indicate if this is a State of Texas License No. or Military Spec. Code No. by checking the appropriate box. A licensed physician in the state of Texas or a physician on duty with the U.S. military must enter his or her license number (one letter and four digits) or a military specialty code next to the applicable box.
- Date Signed —The physician must enter the date (MMDDYYYY) he or she signed Form 3074.
- Print Name of Hospice Physician (Last, First) — Print the hospice physician's name.
- Signature — Hospice Physician — The hospice physician must sign Form 3074. If the individual has an attending physician, the attending and hospice physicians must sign the initial certification statement. If the individual does not have an attending physician, the hospice physician will provide the only certification signature. These signatures must be within the six month certification/recertification time frame.
- Check Appropriate Box and Enter Number — The physician must indicate if this is a State of Texas License No. or Military Spec. Code No. by checking the appropriate box. A licensed physician in the state of Texas or a physician on duty with the U.S. military must enter his or her license number (one letter and four digits) or a military specialty code next to the applicable box.
- Date Signed — The physician must enter the date (MMDDYYYY) he or she signed the form. The physician(s) who sign and date Form 3074 must hold a current, active physician—s license in the state of Texas or be on duty with the U.S. military. Enter a military specialty code in box number 20 if the physician is on duty military. If the attending physician is a resident or holds a temporary license, the supervising physician must complete, sign and date this form.
- Signature — Hospice Staff — A member of the hospice staff must sign the exclusion statement if the individual does not have an attending physician separate from the hospice physician.
- Date Signed — The hospice staff must enter the date (MMDDYYYY) he or she signed the exclusion statement.