To be used by the following to request a statement of medical need from the person’s practitioner:
- Primary Home Care (PHC) and Community Attendant Services (CAS)
- Home and Community Support Services Agencies (HCSSAs)
- Consumer Directed Services (CDS) employer of record
When to Prepare
Form 3052 is completed for initial referrals for PHC and CAS, and for referrals for people whose initial medical need for services was temporary. If a person began services based on a temporary need and the need becomes ongoing, a new Form 3052 is required.
- Completes Part I, Person’s Information, and Part II, HCSSA’s or Financial Management Services Agency’s (FMSA’s) Statement, and any other relevant information on Form 3052. They then send to the person’s practitioner.
- May mail, fax or hand-deliver Form 3052 to the practitioner for signature.
- Sends the completed Form 3052 to the Texas Health and Human Services Commission (HHSC) regional nurse and keeps a copy for their file.
For CDS, the employer of record completes Part I, Person’s Information, and sends it to the practitioner to complete Part III, Practitioner’s Statement and Certifications. The person’s practitioner enters other relevant information and signs and dates Form 3052 to attest to the person’s need for services based on a medical diagnosis resulting in a functional limitation. The practitioner keeps a copy for their file and returns the form to the employer to send to the Financial Management Services Agency (FMSA) to complete Part II, HCSSA's or FMSA's Statement. The completed form is returned to the employer who then sends the form to the HHSC regional nurse. The employer keeps a copy of Form 3052.
The HHSC regional nurse must keep Form 3052 in the person’s file for the duration of services and keep the form as a part of case record for seven years after the case is closed. The HCSSA keeps a copy of the Form 3052 in the person’s file for the duration of services.
Part I, Person's Information
The HCSSA or employer must complete Part I, Person’s Information.
Name — Enter the person’s full name as it appears on Form 2101, Authorization for Community Care Services.
Individual No. — Enter the person’s Medicaid number.
Address — Enter the person’s home address.
HCSSA or Employer Name — Enter the complete name of the HCSSA or employer requesting the practitioner's statement.
Supervisor — Enter the complete name of the supervisor assigned to the person. Not applicable for CDS.
Area Code and Phone No. — Enter the supervisor's complete office phone number, including the area code.
HCSSA or Employer Address — Enter the HCSSA's or employer's full address, including the ZIP code.
Part II. HCSSA’s or 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:
- Search Exclusions | Inspector General (texas.gov)
- Search the Exclusions Database | Office of Inspector General (hhs.gov)
HCSSA or FMSA Representative's Name — Type or print the name of the HCSSA or FMSA representative who verifies that the practitioner is not excluded from participation in Medicare or Medicaid.
Signature – HCSSA or FMSA Representative — The HCSSA or FMSA representative responsible for the verification must sign the form.
Signature Date — The HCSSA or FMSA representative enters the date they sign the form.
Part III. Practitioner's Statement and Certifications
Check All Functional Limitations Related to the Medical Diagnoses — The certifying practitioner enters a check mark by all functional limitations the person has that are related to the medical diagnosis(es).
Part IV. Medical Diagnosis(es)
List Medical Diagnosis(es) Resulting in Functional Limitation(s) — The certifying practitioner enters the medical diagnosis or diagnoses which result in functional limitation(s) of the person.
Statement of Medical Need — By signing the form, the practitioner certifies the person 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 person and a review of the person's medical record within the past 12 months.
If the person's need is ongoing, then no end date is required. If the person's medical need is temporary, the practitioner enters the anticipated end date of medical diagnosis.
The practitioner must also certify that they are not an owner, partner or member of the service provider requesting completion of the practitioner's statement.
Signature – Practitioner — The practitioner signs their name, including credentials.
Signature Date — The practitioner enters the date they sign 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 No. — Enter the practitioner's license number.
Individual NPI No. — Enter 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 such as 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 Phone No. — Enter the practitioner's office phone number, including area code.