The case manager keeps a copy in the person’s case record and sends copies to the provider as required by the program. See Community Care Services Eligibility Handbook, Appendix XIII, Content of Referral Packets, for requirements. All content on this website, including dictionary, thesaurus, literature, geography, and other reference data is for informational purposes only.

  1. Schedule or Authorized Hours — The supervisor or his designee must initial corrections to the schedule or authorized hours and include the effective date of the change.
  2. Circular logic decrees that the lack of a solution is the problem.
  3. It is typically one part – a very important part – of the larger project narrative that carries the reader from the defined need into discussion of specifically how the applicant aims to address that need.
  4. End Users do not act for or on behalf of the CMS.
  5. Complete one Form 3054 for each attendant assigned to provide services to each individual receiving services.

All authorizations must be completed in the Service Authorization System Online (SASO) Wizards. Additionally, you must provide and are responsible for all equipment necessary to access the Service. The well-written abstract is the single most important part of the proposal. Often, initial proposal review, or “first cuts”, are based on the abstract alone.

When an attendant provides services to a individual to prevent a break in service, the attendant’s schedule on Form 3054 must match the schedule designated for the previous attendant. When an attendant provides services to an individual to prevent a break in service, the attendant’s tasks must be reflected on the attendant’s Form 3054. If more than one employee serves the individual, list employee name(s) — List the names of other attendants if there are multiple attendants assigned to provide services to the individual.

If the provider agency has more than one contract with DADS, the nine-digit contract number may be entered here to identify the specific service delivery contract. Complete one Form 3054 for each attendant assigned to provide services to each individual receiving services. State and federal government websites often end in .gov. Before sharing sensitive information, make sure you’re on an official government site.

Individual NPI No. — Enter the practitioner’s individual National Provider Identifier (NPI) number. Signature Date — The HCSSA or FMSA representative enters the date they sign the form. Area Code and Phone No. — Enter the supervisor’s complete office phone number, including the area code. HCSSA or Employer Name — Enter the complete name of the HCSSA or employer requesting the practitioner’s statement.

For DAHS and HDM, the contracted agency must complete Form 2101 and return to the case manager. Diagnosis — HHSC regional nurse enters the diagnosis or diagnoses from Form 3055 (for DAHS). This includes diagnosis of AIDS or HIV infection.

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. Phone No. — The contracted agency enters the phone number of the provider contact person. License No. — Enter the practitioner’s license number.

Instructions for Opening a Form

As of today, no separate filing guidelines for the form are provided by the issuing department. Signature – HCSSA or FMSA Representative — The HCSSA or FMSA representative responsible for the verification must sign the form. HCSSA or FMSA Representative’s Name — Type or print the form 3052 name of the HCSSA or FMSA representative who verifies that the practitioner is not excluded from participation in Medicare or Medicaid. Supervisor — Enter the complete name of the supervisor assigned to the person. The HCSSA or employer must complete Part I, Person’s Information.


If the provider agency fails to complete or correct Form 3054 according to instructions or complete or correct an alternate form, financial errors may result. For PHC, CAS and FC, based on 40 Texas Administrative Code §47. 61(b), the provider must notify the case manager of service initiation. It is up to the provider if Form 2101 is used or if another written document is used for the notification. For AFC, PHC, CAS, ERS, FC and RC, the contracted agency may complete and return the bottom portion of this form.

How To Write A Needs Statement For Your Grant Proposal

Grant Training Center cannot and will not be liable for any loss or damage from your failure to comply with this security obligation. Your needs statement should avoid circular reasoning, a common error in grant proposals. In some situations, when there are gains on the dispositions of the property, the installment method may be used. Proceeds from an installment sale can come in later tax years, which are reported unless the taxpayer is not using the installment method. Form 3052 Practitioner’s Statement of Medical Need and form instructions have been updated for a better understanding of the differences between Medicare and Medicaid home health services and eligibility.

Use statistics that support your argument as well as comparative statistics and research. Service users must be treated as, and communicated with, as equals. Their needs and preferences must be identified and applied consistently during the provision of care. Service users have a right to be involved in, and make informed decisions about, their lives, their finances and their personal health care.

If the individual’s medical need is temporary, the practitioner enters the anticipated end date of medical diagnosis. Form 3052 is completed for initial referrals for PHC and CAS, and for referrals for individuals whose initial medical need for services was temporary. If an individual began services based on a temporary need and the need becomes ongoing, a new Form 3052 is required. Providing medical regulatory authorities, hospitals, and other organizations with access to verification reports on medical credentials requested by individual physicians.

FAIMER remains dedicated to supporting training programs and foreign national physicians through this challenging time. If the individual’s need is ongoing, then no end date is required. Avoid circular logic in your thinking and in the development of your statement of need. Circular logic decrees that the lack of a solution is the problem. Requesting scholarship funds as a solution to the lack of scholarship funds is an example of circular logic.

A more convincing argument is based on a problem with a much larger scope. For example, women are greatly underrepresented in engineering-related fields and scholarship funds will enable more women to pursue engineering as a career choice. Look at your current demographics on your services, programs, and target population and use this to bolster your argument. The taxpayer must input their name and identification number—an employer identification number for a corporation or a Social Security Number for an individual. The next section deals with information about the property, including description, and date of acquisition and sale.

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 CCSE staff. If applying for CAS, CCSE staff forward Form 3052 to the regional nurse.

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