To be used by Primary Home Care (PHC) and Community Attendant Services (CAS) Home and Community Support Services Agencies (HCSSAs) to request a statement of medical need from the individual's practitioner.

If the practitioner is practicing in a military facility or VA facility and not licensed in Texas, enter the state of licensure, unless the NPI number is provided. Get Form Description of materials required, work to be done, special equipment needed, etc. AF FORM 9 Request for Purchase : XFDL: DOC: AF FORM 15 Invoice: XFDL: XFDL: AF FORM 315 AVFUEL Invoice : XFDL: XFDL: AF FORM 332 Base Civil Engineer Work Request : XFDL: XFDL: AF FORM 616 Fund City Authorization (FCA) XFDL: XFDL: AF FORM 1408 Nonappropriated Fund Call Register : XFDL: XFDL: AF FORM 1477 Construction Inspection Record : XFDL : XFDL: AF FORM … Signature – HCSSA/FMSA Representative — The HCSSA/FMSA representative responsible for the verification must sign the form. function() { Practitioner's Name — Type or print the practitioner's first and last name. When a minor under the age of 16 applies for a passport and one of the minor's parents or legal guardians is unavailable Subpart 3052.1 - Instructions for Using Provisions and Clauses 3052.101 Using part 3052.
ADDRESSCONTRACTOR, INSTRUCTIONS FOR COMPLETING AF FORM 3052 (Reverse of AF Form 3052) (Copy for 4 CES/CEC/Bj/Jul 04) 0.00 0.00 0.00 0.00 0.10 0.00 0.10 0.00 0.00 0.00 0.00 0.00-3.00 FOR OFFICIAL USE ONLY 4FOR OFFICIAL USE, (AF Form 3052., AUG 93) Col 1 Item.

Area Code and Telephone No.

Painting Worksheet Example. Supervisor — Enter the complete name of the supervisor assigned to the individual. If the individual's medical need is temporary, the practitioner enters the anticipated end date of medical diagnosis. Search by keywords in the form's instructions. Click this button to scroll back to the top. Please reload CAPTCHA. pdf AF Form 3052 AF Form 3065 Excel 3064C Form AF Form 3064 - Contract Progress Schedule www. docstoc*com Business Business Letters If the contract calls for more than 11 work elements additional copies of the AF Form 3064 may be used as a continuation for the work elements. If an individual began services based on a temporary need and the need becomes ongoing, a new Form 3052 is required.

Form 3052 is completed for initial referrals for PHC and CAS, and for referrals for individuals whose initial medical need for services was temporary. Get the af 3052 form Description of af 3052 SOLICITATION: FA468615R0008 ATTACHMENT #2 Page 1 of 2DATECONSTRUCTION COST ESTIMATE BREAKDOWN ADDRESSCONTRACTOR CONTRACT FOR (Work to be performed)PROPOSED TOTAL CONTRACT PRICE$ PURCHASE REQUEST … Subpart 3052.2 - Text of Provisions and Clauses 3052.203-70 Instructions for Contractor Disclosure of Violations.

Individual No.

7 Itms and units of measure will The EFMP Family Support provider completes the DD Form 3054 through collaboration with families. This guide has been developed primarily for use within AETC to explain the detailed Government Estimate requirement at . Af form 1562.

HCSSA/Employer Address — Enter the HCSSA's/employer's full address, including the ZIP code. timeout Af form 3064. pdf FREE PDF DOWNLOAD NOW Related searches for af form 3064 Af 3064 Sample. List Medical Diagnosis(es) Resulting in Functional Limitation(s) and Corresponding ICD-10 Code(s) — The certifying practitioner enters the medical diagnosis or diagnoses which result in functional limitation(s) of the individual and the corresponding ICD-10 code(s). Not applicable for CDS. pdf AF Form 3052 AF Form 3065 Excel 3064C Form AF Form 3064 - Contract Progress Schedule www. Do not use spaces when performing a product number/title search (e.g. Texas Health & Human Services Commission. — Enter the practitioner's office telephone number, including area code.

); — Enter the practitioner's license number or the practitioner's individual National Provider Identifier (NPI) number. The PHC/CAS HCSSA may complete Form 3052 online as long as the HCSSA retains the practitioner's signature on file. ĞÏࡱá > şÿ Q şÿÿÿ ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿıÿÿÿT Fill & Sign Online, Print, Email, Fax, or Download The information collected on this form is used in conjunction with the DS-11, "Application for a U.S. - 1988 CONTRACT FOR (Work to be performed)PROPOSED TOTAL CONTRACT PRICE$ pubs: AFMAN33-361; forms: AFTO53, AF673, AFSPC1648) To minimize results, use the navigation buttons below to find the level/organization you are looking for, then use the "Filter" to search at that level Col 2 Unit of Measure. PK ! Signature Date — The HCSSA/FMSA representative enters the date he signs the form. Texas Electronic Benefit Transfer Program, Form 3052, Practitioner's Statement of Medical Need, Select the folder you want to save the file in and then click ", Navigate to the folder you saved the file in and, https://oig.hhsc.state.tx.us/Exclusions/Search.aspx, http://www.oig.hhs.gov/fraud/exclusions.asp.

Visit your local installation EFMP Family Support Office to learn more about the DD Form 3054, and how it can help your family! Constractor's estimate of quantity required in terms of unit of measure (couldmn 2). AF Form 3052. Time limit is exhausted. The HCSSA retains a copy of the Form 3052 in the individual's file for the duration of services. Practitioner's Medical Title — Check the appropriate box for the practitioner's medical title: MD (Doctor of Medicine), DO (Doctor of Osteopathy), APN (Advanced Practice Nurse), or PA (Physician Assistant). Maintenance Example.

© Copyright 2016-2020. Your email address will not be published. docstoc*com Business Business Letters If the contract calls for more than 11 work elements additional copies of the AF Form 3064 may be used as a continuation for the work elements. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds.

Signature – Practitioner — The practitioner signs his name, including credentials. INSTRUCTIONS FOR COMPLETING AF FORM 3052 Col 1 Item.

pdf AF Form 3052 AF Form 3065 Excel 3064C Form AF Form 3064 - Contract Progress Schedule www.

The HCSSA completes Part I, Individual Information, and Part II, HCSSA’s/Financial Management Services Agency’s (FMSA’s) Statement, and any other relevant information on Form 3052 and sends it to the individual's practitioner. Find a testing site. ��p�"r��k���Am|H8. INSTRUCTIONS FOR COMPLETING AF FORM 3052 (Reverse of AF Form 3052) (Copy for 4 CES/CEC/Bj/Jul 04) 0.00 0.00 0.00 0.00 0.10 0.00 0.10 0.00 0.00 0.00 0.00 0.00-3.00 FOR OFFICIAL USE ONLY 4FOR OFFICIAL USE ONLY 2.00 1.00 3.00 1.00 4.00 1.00 5.00 1.00 6.00 1.00 7.00 8.00 9.00 10.00 11.00. }, Related Forms

Do not enter a group NPI number.

Please reload CAPTCHA. The lists may be checked at the following websites: HCSSA/FMSA Representative's Name — Type or print the name of the HCSSA/FMSA representative who verifies that the practitioner is not excluded from participation in Medicare or Medicaid.

The practitioner must also certify that he is not an owner, partner or member of the service provider requesting completion of the practitioner's statement.

})(120000); Get the af 3052 form Description of af 3052 SOLICITATION: FA468615R0008 ATTACHMENT #2 Page 1 of 2DATECONSTRUCTION COST ESTIMATE BREAKDOWN ADDRESSCONTRACTOR CONTRACT FOR (Work to be performed)PROPOSED TOTAL CONTRACT PRICE$ PURCHASE REQUEST …. Passport."

! " — Enter the supervisor's complete office telephone number, including the area code. The DD Form 3054 is a living document and can be updated to reflect a family’s changing needs.

General Services Worksheet Example.

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setTimeout( Fill & Sign Online, Print, Email, Fax, or Download. The HHSC case worker or HHSC regional nurse must keep Form 3052 in the individual's file as part of the case record for three years and 90 days after the case is closed. The employer keeps a copy of Form 3052. For CDS, the employer of record completes Part I, Individual Information, and sends it to the practitioner to complete Part III, Practitioner’s Statement and Certifications. — Enter the individual's number as it appears on Form 2101.

Available for PC, iOS and Android. Start a free trial now to save yourself time and money! INSTRUCTIONS FOR COMPLETING AF FORM 3052 (Reverse of AF Form 3052) (Copy for 4 CES/CEC/Bj/Jul 04) 0.00 0.00 0.00 0.00 0.10 0.00 0.10 0.00 0.00 0.00 0.00 0.00-3.00 FOR OFFICIAL USE ONLY 4FOR OFFICIAL USE ONLY 2.00 1.00 3.00 1.00 4.00 1.00 5.00 1.00 6.00 1.00 7.00 8.00 9.00 10.00 11.00.

State — Enter the state of licensure, either Texas or a contiguous state (Arkansas, Louisiana, Oklahoma or New Mexico). To be used by the Consumer Directed Services (CDS) employer of record to request a statement of medical need from the individual's practitioner.
When a minor under the age of 16 applies for a passport and one of the minor's parents or legal guardians is unavailable at the time the passport is executed, a completed and notarized DS-3053 can be used as the statement of consent.

Search for another form here. Follow the steps below to download and view the form on a desktop PC or Mac. Form 3052 is completed for initial referrals for PHC and CAS, and for referrals for individuals whose initial medical need for services was temporary. The HCSSA or the FMSA must complete Part II and verify on both the federal and the Texas Lists of Excluded Individuals and Entities that the practitioner is not excluded from participation in Medicare or Medicaid.

INTRODUCTION. ongoing knowledge of the individual and a review of the individual's medical record within the past 12 months.

Available for PC, iOS and Android.


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