CSHCN 2009 > Forms

Forms

Note: Forms printed from the TMHP website at www.tmhp.com will print with larger text than the forms in this appendix.

Benefit Codes: Home Health DME providers must enter Benefit Code: DM3 on all authorization requests and claims. All other providers, including regular DME, use Benefit Code: CSN.

Prior authorization for:

Additional Nutritional Assessment, Counseling, and Products Form and Instructions B-3

Augmentative Communication Devices (ACDs) Form and Instructions B-6

Chest Physiotherapy Devices Form and Instructions B-10

Bone Marrow, Stem Cell, or Renal Transplant Form and Instructions B-14

Dental or Orthodontia Services Form and Instructions B-18

Diapers, Pull-ups, Briefs, or Liners Form and Instructions B-22

Durable Medical Equipment (DME) Form and Instructions B-25

External Insulin Pump Form and Instructions B-34

Hospice Services Form and Instructions B-36

Inpatient Psychiatric Care Form and Instructions B-39

Inpatient Hospital Admission-For Use by Facilities Only Form and Instructions B-42

Inpatient Rehabilitation Admission Form and Instructions B-47

Medical Foods Form and Instructions B-52

Omalizumab Form and Instructions B-55

Palivizumab (Synagis) Form and Instructions B-58

Pulse Oximeter Devices Form and Instructions B-62

Renal Dialysis Treatment Form and Instructions B-65

Respiratory Care-Certified Respiratory Care Practitioner (CRCP) Form and Instructions B-68

Inpatient Surgery-For Surgeons Only Form and Instructions B-70

Outpatient Surgery-For Outpatient Facilities and Surgeons Form and Instructions B-73

Authorization for:

Apnea Monitor Form and Instructions B-77

Hemophilia Blood Factor Products Form and Instructions B-81

Non-Face-to-Face Clinician-Directed Care Coordinated Services Form and Instructions B-84

Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face Clinician-Directed Care Coordination Services B-88

Extension of Outpatient Therapy (TP2) Form and Instructions B-89

Initial Outpatient Therapy (TP1) Form and Instructions B-93

Authorization and Prior Authorization Request B-96

Criteria documentation for:

Criteria for Dental Therapy Under General Anesthesia B-97

Policy About the Criteria for Dental Therapy Under General Anesthesia, Attachment 1 B-99

Documentation of Receipt B-100

Documentation of Receipt (Spanish) B-101

Home Health (Skilled Nursing) Referral and Treatment Plan Form and Instructions B-102

Instructions for Physician/Dentist Assessment Form B-106

Instructions for Physician/Dentist Assessment Form (Spanish) B-107

Physician/Dentist Assessment Form B-108

Reimbursement Request for Transportation of the Remains of Deceased Clients B-110

Vision Care Eyeglass Client Certification Form B-111

Vision Care Eyeglass Client Certification Form (Spanish) B-112

Wheelchair Seating Evaluation Form and Instructions B-113

Provider forms for:

Claim Status Inquiry (CSI) Authorization B-123

Electronic Funds Transfer (EFT) Information and Authorization Agreement B-124

Electronic Remittance and Status (ER&S) Agreement B-126

Instructions for Completing the Provider Information Change Form B-128

Provider Information Change Form B-129

Refund Information Form B-130

Tort Response Form B-131

Department of State Health Services Form to Release CSHCN Services Program Claims History B-132

Department of State Health Services Form to Release CSHCN Services Program Claims History (Spanish) B-133