Texas Medicaid Hospice Program - Physician Certification of Terminal Illness Author: Forms and Handbooks Subject: Form 3074 r n10 - 2014 Created Date: 2:19:17 PM. Form 3074-TMHP January 2006 Texas Medicaid and Healthcare Partnership Use Only 1. Hospice Provider Name 2. Provider Address (Street or P.O. Box, City, State, Zip) 4. Correction (check if applicable) 5. Recipient Name (Last, First, Middle) 6. DADS Medicaid No. Social Security No. Election/Start Date 10. Hospice providers are responsible for transmitting Form 3074 electronically on the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Online Portal. Hospice providers must send a copy of Form 3074 to the nursing facility (NF) or the intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), if applicable. Texas medicaid hospice program form 3074.

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