Effective Date: 
5/2018

Documents

Instructions

Updated: 5/2018

Purpose

To notify provider agencies about critical omissions or errors in documentation required for approval of Primary Home Care and Community Attendant Services.

Procedure

When to Prepare

The HHSC regional nurse completes Form 3070-A when the documentation submitted by the provider agency for approval contains critical omissions or errors that must be corrected before approval.

Number of Copies

Prepare an original Form 3070-A and one copy.

Transmittal and Form Retention

The regional nurse sends the original to the provider agency when the approval packet is returned for correction. The regional nurse keeps a copy of Form 3070-A in the individual's file.

Detailed Instructions

Individual Name (Last, First, Middle) — Enter the individual's full name as it appears on Form 2101.

Individual No. — Enter the individual's number as it appears on Form 2101.

Provider Agency Name — Enter the complete name of the provider agency.

Vendor No. — Enter the provider agency's vendor number as it appears on Form 2101.

Form 3052, Practitioner’s Statement of Medical Need — Check each critical error or omission that applies to Form 3052. There may be more than one critical omission in the approval request packet.

Due Date — The due date for return of the corrections to the critical omissions is five days from the date Form 3070-A is mailed to the provider agency. (Count the first day after the mail date as day one.)

Additional Explanation — Use this space to provide details or additional information about the items checked.

Signature - Regional Nurse — The regional nurse signs his or her name, including credentials.

Date — The regional nurse enters the date he or she completes Form 3070-A.

Telephone No. — The regional nurse enters his or her telephone number, including area code.

 

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