Effective Date: 
5/2018

Documents

Instructions

Updated: 5/2018

Purpose

To be used by Primary Home Care (PHC) and Community Attendant Services (CAS) Home and Community Support Services Agencies (HCSSAs) to request a statement of medical need from the individual's practitioner.

To be used by the Consumer Directed Services (CDS) employer of record to request a statement of medical need from the individual's practitioner.

Procedure

When to Prepare

Form 3052 is completed for initial referrals for PHC and CAS, and for referrals for individuals whose initial medical need for services was temporary. If an individual began services based on a temporary need and the need becomes ongoing, a new Form 3052 is required.

The PHC/CAS HCSSA may complete Form 3052 online as long as the HCSSA retains the practitioner's signature on file.

Transmittal

The HCSSA completes Part I, Individual Information, and Part II, HCSSA’s/Financial Management Services Agency’s (FMSA’s) Statement, and any other relevant information on Form 3052 and sends it to the individual's practitioner. The HCSA may mail, fax or hand-deliver Form 3052 to the practitioner for signature. The HCSSA sends the completed Form 3052 to the Health and Human Services Commission (HHSC) case worker for PHC applicants or the HHSC regional nurse for CAS applicants and keeps a copy for his/her files.

For CDS, the employer of record completes Part I, Individual Information, and sends it to the practitioner to complete Part III, Practitioner’s Statement and Certifications. The individual’s practitioner enters other relevant information and signs and dates Form 3052 to attest to the individual’s need for services based on a medical diagnosis resulting in a functional limitation. The practitioner keeps a copy for his/her files and returns the form to the employer to send to the Financial Management Services Agency (FMSA) to complete Part II, HCSSA's/FMSA's Statement. The completed form is returned to the employer who then sends the form to the HHSC case worker. If applying for CAS, the HHSC case worker forwards Form 3052 to the HHSC regional nurse. The employer keeps a copy of Form 3052.

Form Retention

The HHSC case worker or HHSC regional nurse must keep Form 3052 in the individual's file as part of the case record for three years and 90 days after the case is closed. The HCSSA retains a copy of the Form 3052 in the individual's file for the duration of services.

Detailed Instructions  

Part I, Individual Information

The HCSSA/employer must complete Part I, Individual Information.

Individual Name — Enter the individual's full name as it appears on Form 2101, Authorization for Community Care Services.

Individual No. — Enter the individual's number as it appears on Form 2101. This may be a Medicaid number or a number assigned by HHSC as the individual's number.

Individual Address — Enter the individual's home address.

HCSSA/Employer Name — Enter the complete name of the HCSSA/employer requesting the practitioner's statement.

Supervisor — Enter the complete name of the supervisor assigned to the individual. Not applicable for CDS.

Area Code and Telephone No. — Enter the supervisor's complete office telephone number, including the area code.

HCSSA/Employer Address — Enter the HCSSA's/employer's full address, including the ZIP code.

Part II. HCSSA’s/FMSA’s Statement

The HCSSA or the FMSA must complete Part II and verify on both the federal and the Texas Lists of Excluded Individuals and Entities that the practitioner is not excluded from participation in Medicare or Medicaid. The lists may be checked at the following websites:

  • https://oig.hhsc.state.tx.us/Exclusions/Search.aspx
  • http://www.oig.hhs.gov/fraud/exclusions.asp

HCSSA/FMSA Representative's Name — Type or print the name of the HCSSA/FMSA representative who verifies that the practitioner is not excluded from participation in Medicare or Medicaid.

Signature – HCSSA/FMSA Representative — The HCSSA/FMSA representative responsible for the verification must sign the form.

Signature Date — The HCSSA/FMSA representative enters the date he signs the form.

Part III. Practitioner's Statement and Certifications

Check All Functional Limitations Related To Medical Diagnoses — The certifying practitioner enters a check mark by all functional limitations the individual has that are related to the medical diagnosis(es).

Part IV. Medical Diagnosis(es) and ICD-10 Codes

List Medical Diagnosis(es) Resulting in Functional Limitation(s) and Corresponding ICD-10 Code(s) The certifying practitioner enters the medical diagnosis or diagnoses which result in functional limitation(s) of the individual and the corresponding ICD-10 code(s).

Statement of Medical Need — By signing the form, the practitioner certifies the individual has a medical need resulting in a functional limitation that supports the need for personal care based on:

  • evaluation within the past 12 months; or
  • ongoing knowledge of the individual and a review of the individual's medical record within the past 12 months.

If the individual’s need is ongoing, then no end date is required. If the individual's medical need is temporary, the practitioner enters the anticipated end date of medical diagnosis.

The practitioner must also certify that he is not an owner, partner or member of the service provider requesting completion of the practitioner's statement.

Signature – Practitioner — The practitioner signs his name, including credentials.

Signature Date — The practitioner enters the date he signs the statement.

Practitioner's Name — Type or print the practitioner's first and last name.

Practitioner's Medical Title — Check the appropriate box for the practitioner's medical title: MD (Doctor of Medicine), DO (Doctor of Osteopathy), APN (Advanced Practice Nurse), or PA (Physician Assistant).

License or Individual NPI No. — Enter the practitioner's license number or the practitioner's individual National Provider Identifier (NPI) number. Do not enter a group NPI number.

State — Enter the state of licensure, either Texas or a contiguous state (Arkansas, Louisiana, Oklahoma or New Mexico). If the practitioner is practicing in a military facility or VA facility and not licensed in Texas, enter the state of licensure, unless the NPI number is provided.

Military or VA — If the practitioner is practicing in a military facility, including a Veterans Affairs (VA) hospital or medical facility, check the Yes box.

Practitioner's Address — Enter the practitioner's complete address, including ZIP code.

Area Code and Telephone No. — Enter the practitioner's office telephone number, including area code.

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