How to Complete and Submit Form 3071: Election, Update, or Cancellation

Texas Form 3071 is the hospice election, cancellation, or update notice the hospice provider submits to the Texas Health and Human Services Commission (HHSC) when a person enters, leaves, or changes details within the Texas Medicaid Hospice Program. The provider — not the patient or family — completes the paper form with the required signatures, then transmits it electronically through the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Online Portal.¹ Every election must be paired with a matching Form 3074, Physician Certification of Terminal Illness, before HHSC will authorize payment.²

The current form is posted in English and Spanish on the HHSC forms library and on the TMHP Long-Term Care Forms page. Check the revision date at the bottom of the PDF before using a saved copy; HHSC may reject an outdated version.¹

What You Need Before You Start

Have the following in hand before you open the form or log into the portal:

The person’s full legal name and date of birth as shown on official identification.
The Medicaid number from the Your Texas Benefits card. If Medicaid has been applied for but not yet approved, enter “Pending.”¹
Social Security number.
Hospice provider name (the “doing business as” name exactly as it appears on the HHSC Medicaid hospice contract).
The nine-digit contract number from that contract.
The principal terminal ICD-10 diagnosis code from the certifying physician, plus any additional terminal diagnoses.
The attending physician’s name, if the person has one other than the hospice medical director.

At least one of the Medicaid number or SSN is required for the portal to accept the submission. Entering both reduces the risk of a processing delay if one does not match HHSC records.

Completing an Election

Select “Election” on the form in three situations: a first-time hospice election, a re-election after a gap in hospice services, or a transfer from one hospice provider to another. On a transfer, the election date is the date of transfer.²

For an election, enter only a “From” date (the date the person elected hospice) and leave the “To” date blank. Every election form must be signed by the person or their responsible party.¹

Pair the election with a completed Form 3074. Both the 3071 and the 3074 must be submitted and processed before HHSC will issue payment. If a person cancels hospice for any reason and later re-elects, a brand-new 3071 and a new 3074 are both required, no matter how much time has passed.¹

Completing an Update

An update modifies information already on file from a previous election. Select “Update,” enter only a “From” date, and use the Comments box (field 17) to explain what changed. Updates do not require a signature from the person or responsible party.²

Common reasons to submit an update include an added or changed principal diagnosis; a move between home, nursing facility, hospital, or another setting; admission to a skilled nursing facility bed or return to a nursing facility Medicaid bed; a payment change; a physician change; or a change of ownership (CHOW) in which the provider receives a new HHSC contract number and the person’s record must move to the new contract.¹

Completing a Cancellation

A cancellation ends the person’s participation in the Medicaid hospice program. Select “Cancel,” enter only a “To” date (the date services ended or the date of death), leave “From” blank, and enter a cancel code in field 2 to document the reason.¹

The cancel codes are:

13 — Person denied Medicaid.
14 — Person transferred to a service other than hospice.
16 — Person not certified for hospice by a physician.
18 — Person refused to follow the plan of care.
19 — Unsafe environment for hospice staff.
75 — Person died.
76 — Person moved out of the hospice provider’s service area or cannot be located.
77 — Person transferred to another hospice, withdrew, was dissatisfied, or refused service.¹

Signature rules on a cancellation depend on the code. Codes 14 and 77 require the person’s or responsible party’s signature. Cancellations for other reasons, including death, loss of Medicaid eligibility, and physician decertification, do not.²

Setting Codes and the Attending Physician Field

Field 5 asks where the person is currently receiving hospice services. Mark the box that matches the setting:

1 — Home (also used for assisted living facilities).
2 — NF (nursing facility).
3 — Hospital.
4 — Hospice Inpatient Unit.
5 — ICF/IID (intermediate care facility for individuals with intellectual disabilities).
6 — SNF (skilled nursing facility; indicates the person is classified as Medicare for a non-related condition).¹

Field 22 names the attending physician if someone other than the hospice medical director is managing the person’s care. One detail worth watching: if the attending physician is a medical resident or holds a temporary license, the supervising physician must be the one who completes, signs, and dates the form.¹

Who Signs the Form

Elections always require a signature. The person receiving hospice signs if they have legal capacity. If the person is a minor or lacks capacity, a legally authorized representative (LAR) signs instead. Acceptable proof of LAR status includes legal guardianship documentation or a power of attorney covering healthcare decisions.³

HHSC also recognizes an authorized representative (AR) designated through several other methods, including a signed Form H1003 (Appointment of an Authorized Representative), an AR designation on a Your Texas Benefits application, or a signed letter naming the representative that includes the representative’s name, address, and signature.³ Each signature on Form 3071 must be accompanied by a clearly printed name and the date. A missing date or an illegible name is enough for HHSC to reject the form.

Submitting Through the TMHP LTC Online Portal

The hospice provider transmits Form 3071 electronically through the TMHP Long Term Care Online Portal.¹ Before logging in, have a completed paper copy with all required signatures and dates. The portal submission does not replace the paper original; the signed and dated original must be kept in the person’s hospice medical record.⁴

To submit:

Log in to the LTC Online Portal at tmhp.com.
Click “Submit Form” in the blue navigation bar.
From the “Type of Form” dropdown, choose “3071: Recipient Election/Cancellation/Discharge Notice” and click “Enter Form.”
Fill in every field marked with a red dot. Enter at least the Medicaid number or SSN. Select the correct form type (Election, Update, or Cancel), enter the appropriate date, choose the setting code, and enter the ICD-10 diagnosis codes.
Click “Submit Form.” A successful submission returns a document locator number (DLN). If errors appear at the top of the screen, correct them and submit again.⁴

Processing Time, Verification, and Records

TMHP processes hospice forms within 14 workdays for individuals who have Medicaid eligibility.⁵ Once the form is processed, the election, update, or cancellation appears in the person’s Medicaid profile and begins to affect how future claims are handled.

Check status on the LTC Online Portal rather than assuming the form went through. The portal offers status inquiries and status reports.⁵ An unresolved error or a missing paired Form 3074 can hold up authorization and block payment for services already delivered.

Keep the signed and dated paper original in the person’s hospice record. The electronic submission does not satisfy the retention requirement.¹ Filing each 3071 alongside its matching 3074 keeps the documentation ready if a claim is ever audited.

1
Texas Health and Human Services. Form 3071, Individual Election, Cancellation or Update
2
Texas Medicaid & Healthcare Partnership. Long-Term Care (LTC) User Guide for Hospice Providers
3
Texas Health and Human Services. B-3300, Authorized Representative
4
Texas Medicaid & Healthcare Partnership. LTC User Guide for Hospice Providers
5
Texas Health and Human Services. Medicaid Hospice Provider Manual – 4000, Billing and Payment