Texas Form 3055 is the Physician’s Orders form used to authorize Day Activity and Health Services (DAHS) for Medicaid-eligible adults who need daytime nursing supervision. The DAHS provider completes the patient and facility information, the physician documents diagnoses, functional limitations, medications, and certification, and the finished form travels with Forms 3050 and 2101 to the HHSC regional nurse or the assigned managed care organization for review, typically within seven days of receipt.
Where to Download Form 3055
The blank PDF is available on the Texas Health and Human Services website under Regulations → Forms → 3000-3999 series, or directly on the Form 3055 page. If the fillable fields don’t render in your browser’s built-in PDF viewer, open the file in the desktop Adobe Reader application instead.1Texas Health and Human Services. Form 3055, Physician’s Orders (DAHS)
One diagnosis restriction to know before the physician starts: the primary diagnosis on Form 3055 cannot be an intellectual or developmental disability or a mental health condition. Those can appear as secondary diagnoses, but the primary reason for DAHS must be a chronic medical condition requiring nursing care.1Texas Health and Human Services. Form 3055, Physician’s Orders (DAHS)
Completing Form 3055 Section by Section
The form has six sections. The DAHS provider fills in Section I before sending the form to the physician; the physician handles the clinical sections and certification.
Section I: Person’s Information
The DAHS provider enters the person’s last name, first name, and middle initial; date of birth (month, day, year); and Medicaid number. Below that, fill in the DAHS program provider’s name, address, and phone number with area code, plus the full name of the DAHS nurse assigned to the person.1Texas Health and Human Services. Form 3055, Physician’s Orders (DAHS)
Section II: Chronic Medical Diagnoses and ICD-10 Codes
The physician lists all current and pertinent medical diagnoses from the last 24 months, each with the matching ICD-10 code. List diagnoses only, not symptoms. Diabetes, hypertension, and congestive heart failure each get their own line with a code. Writing “fatigue” or “dizziness” in place of the underlying diagnosis is one of the fastest ways to have the packet returned.1Texas Health and Human Services. Form 3055, Physician’s Orders (DAHS)
Section III: Functional Limitations
The physician checks every functional limitation the person has that relates to the diagnoses listed in Section II. These may include mobility, bathing, dressing, eating, or cognition. The regional nurse uses this section to confirm the person actually needs the level of care DAHS provides, so anything applicable belongs there.
Section IV: Special Diet
If the person needs a special diet, such as low-sodium, diabetic, pureed, or thickened liquids, the physician documents the type and any specific instructions. The DAHS facility prepares meals to match these orders.
Section V: Medications and Treatments
List every medication the person takes at home or at the facility, including over-the-counter and PRN (as-needed) medications. For each, include the dosage, route, frequency, and related medical diagnosis, and note whether it is self-administered, given by a caregiver, or administered by the DAHS nurse. Separately, list all therapies, treatments, monitoring, and specific interventions the physician has ordered, with their frequency.1Texas Health and Human Services. Form 3055, Physician’s Orders (DAHS)
Section VI: Physician’s Certification
The physician signs and dates the form, certifying three things: the person has a chronic medical condition requiring care, monitoring, or intervention by a licensed nurse; the primary diagnosis is not an intellectual or developmental disability or a mental health condition; and the physician is not an owner, partner, or member of the DAHS provider requesting the orders. Enter the physician’s individual NPI (not a group NPI) and state medical license number.1Texas Health and Human Services. Form 3055, Physician’s Orders (DAHS)
Section VI also contains a checkbox for “no significant change” from the previous assessment. If the physician checks that box, the DAHS provider must include a copy of the previous assessment with the current packet. Forgetting the previous assessment when the box is checked will delay processing.
Forms Submitted with Form 3055
Form 3055 doesn’t travel alone. The DAHS authorization packet includes two other forms:
- Form 3050, DAHS Health Assessment/Individual Service Plan, completed by the DAHS facility nurse to document the person’s health conditions, symptoms from the last 30 days, and the individualized service plan.2Texas Health and Human Services. Form 3050, DAHS Health Assessment or Individual Service Plan
- Form 2101, Authorization for Community Care Services, the HHSC document used to refer, approve or reauthorize services, and set the coverage start date. The regional nurse pulls the diagnosis and physician’s order date from Form 3055 to complete Form 2101.3Texas Health and Human Services. Form 2101, Authorization for Community Care Services
The regional nurse reviews all three forms together. Missing any one of them sends the packet back.
Where and When to Submit
The completed packet goes to the HHSC regional nurse, or, for members in managed care, the assigned managed care organization (MCO).4Texas Health and Human Services. 5000, Service Requirements
Deadlines depend on how the referral started:
- Case manager-initiated referrals: the DAHS facility must send the referral packet to the regional nurse within 14 calendar days of receiving Form 2101 from the case manager. If the physician’s orders can’t be obtained within that window, the provider sends Form 2067 (Case Information) to the case manager explaining the delay.
- Facility-initiated referrals: the provider must submit the prior approval packet within 30 calendar days after the date of the initial physician’s order, whether verbal or written.
Faxed physician’s orders are acceptable. When the physician faxes a signed copy, no follow-up original signature is needed; the faxed copy with the signature counts.4Texas Health and Human Services. 5000, Service Requirements
What Happens After You Submit
The HHSC regional nurse reviews Form 3055, Form 3050, and the supporting documentation to determine whether the person meets DAHS medical eligibility. Standard turnaround is seven days from receipt of the prior approval request.4Texas Health and Human Services. 5000, Service Requirements
If the medical criteria are met and nothing is missing, the regional nurse approves the request and sends copies of Form 2101 to both the provider and the HHSC case manager. The coverage start date on Form 2101 is typically the date that form is expected to be mailed to the provider, though the nurse can negotiate a different date with the provider and case manager based on the person’s circumstances.
If there are errors or omissions, the regional nurse returns the entire packet with Form 3070 (Day Activity and Health Services Notification of Critical Omissions), which spells out what needs to be fixed. Common reasons packets come back:
- Symptoms listed instead of diagnoses in Section II.
- A group NPI used instead of the physician’s individual NPI.
- The previous assessment not attached when the no-significant-change box is checked in Section VI.
If services are denied outright, the case manager sends the person a written notification explaining the decision.
Renewals and Changes in Condition
DAHS authorizations are typically valid for 12 months, and a physician reassessment is required at least once a year for continued authorization. At renewal, the physician’s assessment cannot be more than 90 days old at the time the authorization request is submitted.5Texas Health and Human Services. 10100, Long Term Services and Supports
Outside the annual cycle, a new Form 3055 is also required when the person transfers to a different DAHS facility or has a significant change in condition. If neither applies, the physician can check the no-significant-change box in Section VI at renewal, but the previous assessment still has to accompany the packet.
MCOs may issue temporary authorizations of at least 30 days (expiring after 60 days) when the physician’s assessment and all required forms haven’t been submitted yet, giving the provider time to finalize paperwork without interrupting attendance.
If DAHS Services Are Denied
If services are denied, reduced, or terminated, the person can request a fair hearing verbally or in writing within 90 calendar days from the date of the action being appealed.6Texas Health and Human Services. Appeals and Fair Hearings
To keep receiving services during the appeal, the hearing request must be filed before the effective date shown on Form 2065-A. If it comes in after that date, services stop during the appeal unless the hearings office later finds good cause for the delay. Even a request that arrives past the 90-day window cannot be refused by a caseworker; the hearings office decides whether the late filing had good cause. Form 2065-A includes a checkbox the person can mark and return to initiate the hearing.