How to Fill Out and Submit Texas HHS Form 3050: DAHS Plan of Care

Texas HHS Form 3050 is the DAHS Health Assessment or Individual Service Plan, the document a Day Activity and Health Services facility nurse completes to establish a client’s medical eligibility for the program. The facility nurse fills in the clinical assessment and service plan, the client or responsible party signs, and the facility faxes the form to HHSC along with the physician’s orders and the community care authorization form. A regional nurse then reviews the packet and issues the approval.

Because the regional nurse’s decision rests almost entirely on what the facility nurse writes on this one form, care with each section is what separates a five-business-day approval from a rejection notice and a 14-day scramble to fix it.

What Form 3050 Covers

The form has two jobs on one document. The first half is a health assessment: diagnoses, functional limitations, vital signs, and behavioral patterns within the last 30 days. The second half is an individual service plan spelling out the personal care, grooming help, medication assistance, and therapies the client will receive at the DAHS facility.¹ Together, the two halves give the HHSC regional nurse everything needed to decide medical eligibility.

One quick clarification, because the numbers look similar: Form 3050 has nothing to do with nurse aide certification. The nurse aide performance record is a separate document, Form 5497-NATCEP.²

Who Completes and Signs the Form

The DAHS facility nurse fills out Form 3050. Depending on the client’s presenting health conditions, that can be a Registered Nurse or a Licensed Vocational Nurse employed by the facility.³ The client or responsible party (a family member or legal guardian) does not complete any clinical sections but must sign the form every time the nurse completes or revises it.

When To Prepare a New Form 3050

A brand-new Form 3050 is required in four situations:¹

Initial prior approval for a new applicant.
Transfer of a client from another DAHS facility.
The annual reassessment of a current client.
A significant change in the client’s condition, or new or supplemental physician’s orders that alter nursing services.

The facility must complete Form 3050 annually before DAHS service authorization can be renewed.⁴ Small updates, like a new medication, can be entered in the Additional Information/Notes area of an existing form. A significant change calls for a fresh form completed from scratch.

Filling Out Each Section

The form is a PDF download from the Texas Health and Human Services website. Some browsers won’t display it inline, so opening it directly in Adobe Reader is often necessary.¹ Sections II, III, and IV must all be completed together during the initial assessment.³

Section I: Identification and Background

Enter the client’s last name, first name, and middle initial, along with date of birth, sex, and Medicaid ID number. Record the start of care date (the date of initial admission to the DAHS facility) and whether the client lives alone. Check “Initial” for a first-time applicant, “Transfer” for a client coming from another facility, or “Reassessment” for an annual update. The bottom captures the facility’s name, address, phone number, and the name of the nurse completing the form.

Section II: Assessment of Functional and Physical Status

This is the clinical heart of the form. Subsections A through I cover disease diagnoses, communication and hearing, vision, problem behaviors, continence, skin condition, oral and dental status, body control problems, and nutrition. Check every problem, condition, or symptom the client has shown in the last 30 days, and add comments wherever the checkbox alone doesn’t fully explain the monitoring, treatment, or intervention needed. Where the physician has issued relevant orders, reference Form 3055, Physician’s Orders (DAHS).

Subsection J records vital signs, height, weight, and blood sugar readings taken at the time of the assessment. Enter each reading as applicable. This is what the regional nurse compares against the physician’s orders to confirm the medical condition warrants DAHS.

Section III: Therapies and Treatments

List every therapy the client currently receives from any source: respiratory therapy, occupational therapy, physical therapy, chemotherapy, and any other active treatment. Complete each item as it stands at the time of assessment and add comments to explain anything the checkboxes don’t capture.

Section IV: Plan of Care

Section IV translates the assessment into an actionable service plan. Subsections A through E cover aids the client uses (cane, walker, wheelchair) and the level of staff assistance needed for transfers, locomotion, eating, toileting, and similar activities. For each area, enter the schedule and frequency of assistance along with any relevant comments.

Subsection F is dressing and grooming: check the types of grooming help, the staff assistance level, and note the frequency. Subsection G addresses assistance with self-administered medications while the client is at the facility. Check whether help is needed and specify the schedule for each medication. The Additional Information/Notes area at the end of Section IV is where the nurse later documents any new treatments added after the initial assessment, with clear dates so a reviewer can see what’s current.

Section V: Therapeutic Benefit

This is a narrative section, not a checkbox. Describe how the client will benefit therapeutically from attending DAHS by connecting the functional limitations identified in Section II to the services outlined in Section IV, and explaining why structured daytime care will improve or maintain the client’s condition. The facility nurse signs and dates this section, certifying that the client has a chronic medical condition and that the physician states the client will benefit therapeutically from DAHS.

Section VI: Participation in Assessment

The individual or responsible party signs and dates the form. This signature is required every time the facility nurse completes or revises Form 3050.³ The nurse also signs with a date and phone number.

Documents To Submit With Form 3050

Form 3050 by itself will not get a client approved. It must go in with two companion documents:

Form 3055, Physician’s Orders (DAHS), certifying the chronic medical condition and authorizing DAHS.
Form 2101, Authorization for Community Care Services, which tracks the service approval decision.

The HHSC regional nurse reviews all three together.⁵ A missing companion form will stall the process.

Where To Send It and What Happens After

DAHS facilities fax the completed Form 3050 with its companion documents to 877-940-1972.⁴ The HHSC regional nurse then reviews the documentation to confirm medical eligibility. If the applicant qualifies and the paperwork is clean, the regional nurse generates the authorization on Form 2101 and sends it to the facility and Community Care Services Eligibility staff within five business days of receiving the prior approval request.⁵

If the regional nurse finds errors or omissions, the facility receives Form 3070, Day Activity and Health Services Notification of Critical Omissions, along with the rejected packet. The facility has 14 calendar days from the mailing date of Form 3070 to correct the problems and resubmit. Common triggers for a critical omissions notice include blank clinical subsections, a Section V narrative that fails to connect the functional limitations to therapeutic benefit, a missing client or responsible party signature, and submission without a matching Form 3055 from the physician.

Who DAHS Serves

Before starting the form, confirm the client meets the basic DAHS criteria: Medicaid eligibility (or meeting income and resource thresholds), an unmet need not already covered by another Community Care Services Eligibility program, a chronic medical diagnosis with physician’s orders, and at least one functional limitation with the potential to benefit therapeutically from care at a DAHS facility.⁵ DAHS is limited to adults 18 and older. People living in institutional settings such as skilled nursing facilities or intermediate care facilities are not eligible. A person who needs fewer than three hours weekly does not qualify, and authorization is capped at 10 units per week.

Keeping the Form Current After Approval

Form 3050 is a living document. The facility nurse must update the assessment whenever it no longer accurately reflects the client’s conditions or symptoms, including changes in treatment, monitoring, or interventions, and any new or supplemental physician’s orders that alter nursing service needs.³

Documentation of the frequency of treatments, monitoring, and interventions in the service plan should be clearly linked to internal records the facility maintains, so HHSC monitoring staff can verify the assistance actually being provided. For a minor change like a new medication, note it in the Additional Information/Notes area of Section IV with a clear date. When the overall plan of care no longer meets the client’s needs, complete a fresh Form 3050 from scratch rather than annotating the old one.¹

1
Texas Health and Human Services. Form 3050, DAHS Health Assessment or Individual Service Plan
2
Texas Health and Human Services. Form 5497-NATCEP, Texas Nurse Aide Performance Record
3
Texas Health and Human Services. 5000, Service Requirements
4
UnitedHealthcare. Day Activity and Health Services (DAHS) Form Requirements
5
Texas Health and Human Services. 4200, Day Activity and Health Services