Form 3050, DAHS Health Assessment/Individual Service Plan

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Effective Date: 6/2017


Updated: 6/2017



  • To provide a standardized record of the applicant's/individual's health assessment/service plan while attending Day Activity and Health Services (DAHS).
  • To provide the Texas Health and Human Services Commission (HHSC) regional nurse with information required to determine if the applicant/individual/member meets the DAHS medical eligibility criteria.

When to Prepare

Form 3050 is completed by the DAHS facility nurse for DAHS applicants/individuals/members:

  • who need initial prior approval;
  • who transfer from one facility to another;
  • when the licensed nurse determines an individual needs a new service plan developed; or
  • for an individual whose nursing services needs have been changed to reflect supplemental physician’s orders so long as the form remains legible.

Number of Copies

Prepare an original and one copy of Form 3050.


Send one copy to the HHSC regional nurse or managed care organization (MCO) when requesting prior approval of DAHS.

Form Retention

For ongoing services, the provider keeps Form 3050 for the duration of services to the individual/member. For terminated services, the provider keeps Form 3050 in the individual's/member's health record for five years, or until HHSC audits the agency and all audit exceptions are resolved, whichever is later.

Supply Source

This form is found on the HHS website.

Detailed Instructions

Section I — Identification and Background Information

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's/Member's Medicaid ID Number — Enter the individual’s/member's Medicaid ID number.

Start of Care Date — Enter the date of initial admission into the DAHS facility.

Sex — Check Male or Female.

Lives Alone — Check Yes or No.

Reason for Assessment — Check the appropriate box.

  • Initial — for an initial approval;
  • Transfer — for an individual who is transferring from another DAHS facility; or
  • Reassessment — if completing an annual assessment for an individual's/member's service plan.

DAHS Facility Name — Enter the facility name.

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

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

DAHS Facility Address — Enter the DAHS facility address.

Section II — Assessment of Functional/Physical Status

Sections A through I — Check all problems/conditions/symptoms experienced within the last 30 days and, if needed, comments to adequately explain the monitoring, treatments and interventions. Refer to Form 3055, Physician's Orders (DAHS), if necessary.

Section J, Vital Signs/Height/Weight/Blood Sugar — Enter the readings, as indicated at the time of assessment, as applicable.

Section III — Therapies and Treatments

Complete each item as indicated at the time of assessment. Add comments, if necessary, to explain any relevant information.

Section IV — Plan of Care: Personal Care at the DAHS Facility

A through E — Check the type(s) of aids used by the individual/member and the type of staff assistance needed by the individual/member. Enter the schedule/frequency of assistance provided and appropriate comments.

F. Dressing and Grooming — Check the type(s) of grooming assistance and staff assistance needed by the individual/member.  Enter the schedule/frequency and comments, as needed.

G. Assistance with Self-Administer Medication While Attending DAHS — Check if the individual/member requires assistance with self-administering medication. Enter the schedule/frequency for each medication.

Additional Information/Notes — Enter additional information, as needed. When new treatments are added, the facility nurse can enter when the new treatments started in this section. The information needs to clearly indicate to an external reader that the information is related to the current plan of care. If a significant change in condition occurs and the current plan of care no longer meets the individual’s/member’s needs, a new Form 3050 should be completed.

Section V — Therapeutically Benefit

Indicate how the individual/member will benefit therapeutically in receiving DAHS.

Examples of therapeutically benefit:

  • Gout — Promoting management of gout flare-ups per physician's orders by offering recommended dietary choices at lunch and assistance with medication during flare-ups.
  • Coronary Heart Disease — Promoting high blood pressure control per physician's orders by offering recommended dietary choices at lunch and exercise during DAHS activities.
  • Vascular Dementia — Encouraging social interaction in the DAHS facility to promote socialization and intellectual stimulation due to high risk for altered self-image and isolations related to the disease process.

Section VI — Participation in Assessment

Indicate who provided the information for the assessment. The individual/member and/or responsible party who participated in the assessment signs on the line provided in the signature section.


The individual/member and/or responsible person signs and dates the form.

The facility nurse signs and dates the form, certifying this individual/member has a chronic medical condition and the physician states the individual/member will benefit therapeutically from DAHS. The nurse prints his/her name and enters his/her area code and telephone number.