Form 3627, Specialized Nursing Certification

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Effective Date: 6/2008


Updated: 6/2008


The specialized nursing certification form documents the Community Living Assistance and Support Services (CLASS) and the Deaf Blind with Multiple Disability (DBMD) participant's need for specialized nursing.


When to Prepare

The registered nurse (RN) completes Form 3627 when the participant requires tracheostomy care or uses a ventilator. This form must be completed at least annually at the time of the reassessment individual service plan (ISP).

Number of Copies

The direct service agency (DSA)/provider agency's RN completes the original Form 3627. A copy is given to the case management agency (CMA).


The DSA/provider agency keeps the original in the participant's record and sends a copy to the CMA. The case manager must send a copy with the ISP change adding specialized nursing to the ISP or with the reassessment ISP that has specialized nursing services to HHSC CLASS/DBMD program staff for authorization.

Form Retention

The DSA and the CMA keep Form 3627 according to the retention requirements of the CLASS/DBMD program.

Detailed Instructions

Criteria — At least one of the criteria must be checked to qualify for the specialized nursing services reimbursement rate.

Signature — The DSA/provider agency's registered nurse must sign and date Form 3627.

Provider Agency Name — Enter the DSA/provider agency's name.

Provider Contract No. — Enter the DSA/provider agency's contract number.