How to Fill Out Texas Form 3074: Physician Certification of Terminal Illness

To fill out Texas Form 3074, Physician Certification of Terminal Illness, download the current PDF from the Texas Health and Human Services website, enter the hospice provider’s identifying information, complete the patient’s identifiers and election date exactly as they appear on the Your Texas Benefits Medicaid card, mark whether the submission is an initial certification or a recertification, and have the attending physician and the hospice medical director sign and date their blocks within the applicable certification window. The hospice provider then transmits the completed form electronically through the TMHP Long Term Care Online Portal. The physicians certify in writing that the patient’s life expectancy is six months or less if the terminal illness runs its normal course.

Download the Current Form

Form 3074 is posted on the Texas HHS forms page at hhs.texas.gov in the 3000–3999 section. Two versions are available: the English PDF (3074.pdf) and a Spanish version (3074-s.pdf). Hospice providers usually keep blank copies, but attending physicians or families can download them in advance. The paper copy is the source document for signatures and recordkeeping; the actual filing happens electronically.¹

Hospice Provider Information

The top of the form captures the hospice provider’s details. Enter the DBA name, the nine-digit Medicaid contract number, and the address exactly as they appear on the HHSC Medicaid hospice contract. Any mismatch between these fields and the contract on file will cause processing problems.

A checkbox at the top of the form indicates whether the submission is a correction to a previously filed Form 3074. Leave it blank for a first-time submission.

Patient Information

The patient block has to match the Medicaid record exactly. The fields are:

Individual’s Name (Last, First, Middle), copied from the Your Texas Benefits Medicaid card.
HHSC Medicaid Number, from the same card.
Medicare Number, if the patient has one.
Social Security Number.
Election or Start Date, in MMDDYYYY format.
Individual’s Address, meaning the address where hospice services are delivered.

The election date must match the date on the hospice election statement (Form 3071). A mismatch between the two forms will create processing issues downstream.¹

Initial Certification or Recertification

A checkbox field asks whether the form is an initial certification or a recertification, with a corresponding certification date. Pick one and enter the matching date. A new Form 3074 is required for each recertification period, so this field changes every cycle.

Primary Diagnosis

The certification must identify the single condition most directly responsible for the terminal prognosis. This is the diagnosis driving the expected decline and death within six months, not a comorbidity like diabetes or chronic kidney disease that complicates care without being the principal cause. Secondary conditions belong in the medical record and care plan, but the primary diagnosis on Form 3074 is what Medicaid evaluates for eligibility. Vague descriptions and symptom codes will not survive review; the diagnosis has to be specific enough to support a six-month prognosis on its own.

Federal rules also require a brief narrative explanation of the clinical findings that support the prognosis, and the supporting documentation (lab results, imaging, hospital discharge summaries) must be kept in the medical record alongside the written certification.²

Physician Signature Blocks

The lower portion of the form holds two parallel signature blocks: one for the attending physician, one for the hospice physician (medical director). Each physician prints a name, signs, checks a box indicating whether the identifier being supplied is a State of Texas license number or a Military Specialty Code number, enters that number, and dates the signature.

For the initial benefit period, both signatures are required when the patient has an attending physician who is separate from the hospice medical director. If the patient has no separate attending physician, a hospice staff member signs an exclusion statement on the form confirming that fact, and the hospice physician’s signature alone satisfies the requirement.¹

The signature dates matter. Each must fall within the applicable certification or recertification window. A signature dated outside that window can invalidate the certification and delay payment.

Oral Verification Statement

Near the middle of the form is an oral verification section. It applies only during the initial election period. If the hospice cannot obtain a signed written certification within two calendar days of the election, it must at least secure an oral certification from the physician within that same two-day window. A hospice staff member signs and dates the oral verification statement on the form confirming the oral certification was documented in the patient’s record. The written certification still has to be obtained before the hospice submits any claim for payment.¹

Oral certification is not available for recertification periods. Those require a written signature from the start.²

Timing Rules That Affect Payment

The hospice must obtain the written certification within two calendar days of the patient’s initial election of hospice care. If that deadline passes and neither a written nor an oral certification was obtained in time, the effective date for Medicaid payment shifts from the election date to the date the physician actually signed. The hospice absorbs the cost of services provided during the gap.¹

Certifications can be completed up to 15 calendar days before the effective date of the election, which gives providers room to line up signatures when an admission is anticipated.²

Submitting Through the TMHP Portal

The hospice provider, not the patient or family, submits Form 3074 electronically through the TMHP Long Term Care Online Portal. Go to tmhp.com, select Programs, then Long-Term Care (LTC), and click the LTC Online Portal button. Access requires an administrator account linked to the hospice provider. Setting one up for the first time requires the provider’s HHSC-assigned provider number, the four-digit vendor number, and a vendor password available by calling the EDI Help Desk at 888-863-3638.³

Once logged in, click Submit Form on the navigation bar, pick Form 3074 from the dropdown, and enter the patient’s information. Red dots mark required fields. Drafts can be saved and resumed later. A “Correct this form” feature is available for previously submitted forms containing errors, but corrections are not allowed once a form has been inactivated or already corrected. Portal technical support is at 800-626-4117, option 3, Monday through Friday from 7:00 a.m. to 7:00 p.m. Central Time.³

What Changes at Recertification

A new Form 3074 is required for each recertification. Starting with the third benefit period and every period after that, a hospice physician or nurse practitioner must conduct a face-to-face encounter with the patient no more than 30 calendar days before the recertification date. Without that visit, the certification is invalid and the state can recoup payment for any days not covered by a valid certification.²

As of October 1, 2025, the face-to-face attestation must be signed and dated by the practitioner who performed the encounter. A signed and dated clinical note from the visit can serve as the attestation if it includes the patient’s name and the date of the visit. A separate attestation form is no longer required when the clinical note covers those elements.

1
Texas Health and Human Services. Form 3074, Physician Certification of Terminal Illness
2
eCFR. 42 CFR 418.22 Certification of Terminal Illness
3
Texas Medicaid & Healthcare Partnership. Long-Term Care User Guide for Online Portal Basics