To be used by contracted Day Activity and Health Services (DAHS) program providers to request physician’s orders from the person’s physician.
When to Prepare
Form 3055 is completed for:
- initial approval for DAHS;
- new orders determined by the DAHS nurse or managed care organization (MCO) due to changes in the person's condition; and
- new supplemental physician's orders for nursing services.
Number of Copies
Prepare an original and two copies.
The DAHS program provider completes Part I, Information and sends one copy to the person’s physician. The physician completes the remainder of the form.
The DAHS program 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 Texas 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 DAHS program provider must also send the previous assessment.
For ongoing services, the DAHS program provider keeps Form 3055 in the person’s health record for the duration of services. For terminated services, the DAHS program provider keeps Form 3055 in the person’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.
Section I. Person's Information
To Be Completed by Provider:
Name —Enter last, first and middle initial of the person’s name.
Date of Birth — Enter the person’s birth month, day and year.
Individual No. — Enter the person’s Medicaid number.
DAHS Program Provider Name — Enter the complete name of the DAHS program provider requesting the physician's orders.
DAHS Nurse — Enter the complete name of the DAHS program provider nurse assigned to the person.
DAHS Area Code and Phone No. — Enter the telephone number and area code of the DAHS program provider.
DAHS Address — Enter the DAHS program provider 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 person 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 by the DAHS program provider including PRN over-the-counter medications. These medications could be self-administered, administered by caregiver, or by the DAHS RN or LVN. Include the dosage, route and frequency prescription. List the medication the person brings to the DAHS program provider and takes independently or with reminding by the DAHS staff. Indicate the dosage, route, frequency and related medical diagnosis.
Therapies or treatments — List all ordered therapies, treatments, including monitoring, specific interventions or procedures. List frequency and any notes or comments.
Section VI. Physician's Certification
By signing the form, the physician certifies the person has a chronic medical condition as indicated, and care, monitoring or intervention by a licensed nurse as prescribed. The primary diagnosis cannot be an intellectual and development disability or mental health condition.
The physician must also certify that they are 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 person has no significant change in care plan from the previous assessment.
Signature - Physician — The physician must sign their name, including credentials.
Today's Date — The physician enters the date they sign the statement.
Verbal Order Date — The DAHS facility nurse enters this date based on verbal orders from the physician.
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 No. — Enter the physician’s medical license number.
Individual NPI No. — Enter the physician’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 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 Phone No. — Enter the physician’s office phone number and area code.