Form 3230 "Application to Treat Eligible Patients at Their Residence Under the Centers for Medicare and Medicaid Services Acute Hospital Care at Home Program in Response to Covid-19" - Texas

What Is Form 3230?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2021;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 3230 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 3230 "Application to Treat Eligible Patients at Their Residence Under the Centers for Medicare and Medicaid Services Acute Hospital Care at Home Program in Response to Covid-19" - Texas

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Form 3230
February 2021-E
Application to Treat Eligible Patients at Their Residence Under the Centers for
Medicare and Medicaid Services Acute Hospital Care at Home Program in Response to COVID-19
Note: This form is for facilities that have been approved by CMS to participate in the Acute Hospital Care at Home Program.
Section 1 – Requesting Facility Information
Facility Name:
Street Address:
City:
State:
ZIP Code:
Facility Contact Name:
Title:
Contact Area Code and Phone No. (Direct):
Contact Area Code and Phone No. (Mobile):
Contact Area Code and Fax No.
Email:
License Type:
Facility License No.:
Medicare/CMS Certification No.:
Section 2 – Centers for Medicare and Medicaid Services (CMS) Approval and Documentation
HHSC requires facilities to provide approval from CMS. The approval allows the facility to participate in the Acute Hospital Care at Home
Program. Attach this CMS documentation to your email after you select the “Submit by Email” button below.
Section 3 – Attestation
I attest that all information submitted in this application is true and correct. I acknowledge that I understand all the requirements associated with
the approval of this request and that more information may be required. I acknowledge that authority to treat eligible patients at their residence
under the Centers for Medicare and Medicaid Services Acute Hospital Care at Home Program is temporary and subject to the discretion of
HHSC.
Requesting Facility Contact Signature
Date
(Facility Administrator, CEO or Designated Facility Staff Member Signature. Name shall match facility’s primary contact name in Section 1.)
Note: Applicants will receive correspondence via email regarding the status of the application.
For Agency Use Only
The request is granted unless otherwise noted below:
Approved by:
Title:
Approved On:
Form 3230
February 2021-E
Application to Treat Eligible Patients at Their Residence Under the Centers for
Medicare and Medicaid Services Acute Hospital Care at Home Program in Response to COVID-19
Note: This form is for facilities that have been approved by CMS to participate in the Acute Hospital Care at Home Program.
Section 1 – Requesting Facility Information
Facility Name:
Street Address:
City:
State:
ZIP Code:
Facility Contact Name:
Title:
Contact Area Code and Phone No. (Direct):
Contact Area Code and Phone No. (Mobile):
Contact Area Code and Fax No.
Email:
License Type:
Facility License No.:
Medicare/CMS Certification No.:
Section 2 – Centers for Medicare and Medicaid Services (CMS) Approval and Documentation
HHSC requires facilities to provide approval from CMS. The approval allows the facility to participate in the Acute Hospital Care at Home
Program. Attach this CMS documentation to your email after you select the “Submit by Email” button below.
Section 3 – Attestation
I attest that all information submitted in this application is true and correct. I acknowledge that I understand all the requirements associated with
the approval of this request and that more information may be required. I acknowledge that authority to treat eligible patients at their residence
under the Centers for Medicare and Medicaid Services Acute Hospital Care at Home Program is temporary and subject to the discretion of
HHSC.
Requesting Facility Contact Signature
Date
(Facility Administrator, CEO or Designated Facility Staff Member Signature. Name shall match facility’s primary contact name in Section 1.)
Note: Applicants will receive correspondence via email regarding the status of the application.
For Agency Use Only
The request is granted unless otherwise noted below:
Approved by:
Title:
Approved On: