Effective Date: 
6/2017

Documents

 

Instructions

Updated: 6/2017

 

Purpose

To be used by contracted Day Activity and Health Services (DAHS) providers to request physician’s orders from the individual's/member's physician.

When to Prepare

Form 3055 is completed for:

  • initial and annual approval for DAHS;
  • new orders as determined by the DAHS nurse or member's manged care organization (MCO) due to changes in the individual's/member's condition; and
  • new supplemental physician's orders for nursing services.

Number of Copies

Prepare an original and two copies.

Transmittal

The DAHS provider completes Part I, Individual/Member Information, and sends one copy to the individual's/member's physician. The individual's/member's physician completes the remainder of the form. If services are to be authorized on a time-limited basis, the end date of service must be entered.

The DAHS provider keeps the original Form 3055 and sends a copy with Form 3050, DAHS Health Assessment/Individual Service Plan, and Form 2101, Authorization for Community Care Services, to the Health and Human Services Commission (HHSC) regional nurse or MCO to request authorization for DAHS. If a physician notes no significant change in Section VI, Physician's Certification, the facility must also send the previous assessment.

Form Retention

For ongoing services, the provider keeps Form 3055 in the individual's/member's health record for the duration of services. For terminated services, the provider keeps Form 3055 in the individual's/member's health record for five years, or upon closure of the case record until HHSC audits the agency and all audit exceptions are resolved, whichever is later.

 

Detailed Instructions

Section I. Individual/Member Information

To Be Completed by Provider:

Individual/Member Name —Enter last, first and middle initial of the individual's/member's name.

Date of Birth — Enter the month, day and year of the individual’s/member's birth.

Individual/Member Mediciad ID No. — Enter the individual's/member's Medicaid number.

DAHS Facility Name — Enter the complete name of the DAHS facility requesting the physician's orders.

DAHS Nurse — Enter the complete name of the DAHS facility nurse assigned to the individual/member.

DAHS Area Code and Telephone No. — Enter the telephone number of the DAHS facility, including area code.

DAHS Facility Address — Enter the DAHS facility address.

Section II. Chronic Medical Diagnosis(es) from the Last 24 Months and Corresponding ICD-10 Codes(s)

List current and pertinent medical diagnosis or diagnoses from the last 24 months. Do not list symptoms. List the corresponding ICD-10 code(s) for medical diagnoses.

Section III. Functional Limitations Related to Medical Diagnoses

The certifying practitioner enters a check mark by all functional limitations the individual/member has that are related to the medical diagnosis(es).

Section IV. Special Diet

Document the type of diet and instructions, as needed.

Section V. Medications and Treatments

Medications — List all medications administered at home and the DAHS facility including PRN over-the-counter medications. These medications could be self-administered, administered by caregiver, or by the DAHS facility RN or LVN. Include the dosage, route, frequency prescription. List the medication the individual/member brings to the DAHS facility and takes independently or with reminding by the DAHS facility staff. Indicate the dosage, route, frequency and related medical diagnosis.

Section VI. Physician's Certification

By signing the form, the physician certifies the individual/member has a chronic medical condition as indicated, and care, monitoring or intervention by a licensed nurse as prescribed. The primary diagnosis cannnot be an intellectual and development disability or mental health condition.

The physician must also certify that he/she is not an owner, partner or member of the service provider requesting completion of the physician's orders. The physician ordering services signs and dates the form. The date is the day the order was signed. By checking the box and entering the date, the physician certifies the individual/member has no significant change in care plan from the previous assessment.

Signature - Physician — The physician must sign his/her name, including credentials.

Today's Date — The physician enters the date he/she signs the statement.

Effective Date and End Date (if time limited) — For an initial assessment, the date is the effective date services are to begin and the end date is only used if the physician recommends DAHS for a time limited period. For an annual reassessment where there is no significant change in condition, the effective date is the first day after the day the previous certification ended. The end date is only used if the physician recommends DAHS for a time limited period. If services are being authorized on a time-limited basis, enter the last day services should be delivered.

Physician’s Name — Type or print the physician’s first and last name.

Physician’s Medical Title Check the appropriate box for the physician’s medical title: MD (Doctor of Medicine) or DO (Doctor of Osteopathy).

License or NPI No.Enter the physician’s medical license number or the National Provider Identifier (NPI) number.   

StateEnter the state of licensure, either Texas or a contiguous state (Arkansas, Louisiana, Oklahoma or New Mexico). If the physician is practicing in a military facility or Veteran’s Affairs (VA) facility and is not licensed in Texas, enter the state of licensure, unless the NPI number is provided.

Military or VA If the physician is practicing in a military facility, including a VA hospital or medical facility, check the Yes box.

Physician’s Address Enter the physician’s complete address, including ZIP code.

Area Code and Telephone No. Enter the physician’s office telephone number, including the area code.

Having trouble viewing or downloading a form?

Get Help