Form 3070, Day Activity and Health Services Notification of Critical Omissions

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Documents

Effective Date: 10/2015

Instructions

Updated: 10/2015

Purpose

To notify Day Activity and Health Services (DAHS) facilities about critical omissions or errors in documentation required for prior approval.

Procedure

When to Prepare

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

Number of Copies

Prepare Form 3070 in duplicate.

Transmittal and Form Retention

The original is sent to the facility when the prior approval packet is returned for correction. The regional nurse keeps a copy of any Form 3070 related to denials or necessary corrections. Another copy is forwarded to the case manager to retain in the case record.

Detailed Instructions

Check each critical error or omission that applies. Enter the due date as 14 days from the date Form 3070 is expected to be mailed to the facility. (Count the first day after the mail date as day one.)

In the space under each item or in the additional explanation section, provide details or additional information about the items checked.