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Forms
B.1 Abortion Certification Statements Form B-3
B.2 Affidavit B-4
B.3 Ambulance Fax Cover Sheet B-5
B.4 Authorization to Release Confidential Information (2 Pages) B-6
B.5 Authorization to Release Confidential Information (2 Pages) (Spanish) B-8
B.6 Birthing Center Report (Newborn Child or Children) Form 7484 B-10
B.7 Child Abuse Reporting Guidelines (2 Pages) B-11
B.8 Child Abuse Reporting Guidelines, Checklist for HHSC Monitoring B-13
B.9 Claim Status Inquiry (CSI) Authorization Form B-14
B.10 Client Medicaid Identification (Form H3087) (19 Pages) B-15
B.11 Credit Balance Refund Worksheet B-34
B.12 DME Certification and Receipt Form B-35
B.13 Donor Human Milk Request Form B-36
B.14 Electronic Funds Transfer (EFT) Information B-37
B.15 Electronic Funds Transfer (EFT) Authorization Agreement B-38
B.16 External Insulin Pump B-39
B.17 Federally Qualified Health Center Report (Newborn Child or Children) Form 7484 B-40
B.18 Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) B-41
B.19 Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Instructions (2 Pages) B-42
B.20 Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form B-44
B.21 Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form B-45
B.22 Home Health Services Plan of Care (POC) Instructions B-46
B.23 Home Health Services Plan of Care (POC) B-47
B.24 Home Health Services Prior Authorization Checklist B-48
B.25 Hospital Report (Newborn Child or Children) HHSC Form 7484 B-49
B.26 Hysterectomy Acknowledgment Form B-50
B.27 Informational Inquiry Form B-51
B.28 Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device Form-Initial Request B-52
B.29 Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device Form-Extended Request B-53
B.30 Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy B-54
B.31 Medicaid Certificate of Medical Necessity for Reduction Mammaplasty B-55
B.32 Medical Necessity for In-Home Total Parenteral Hyperalimentation (TPN) B-56
B.33 Nursing Addendum to Plan of Care (THSteps-CCP) (7 Pages) B-57
B.34 Other Insurance Form B-64
B.35 Primary Care Case Management (PCCM) Behavioral Health Consent Form B-65
B.36 Primary Care Case Management (PCCM) Behavioral Health Consent Form (Spanish) B-66
B.37 Primary Care Case Management (PCCM) Community Health Services Referral Request Form B-67
B.38 Primary Care Case Management (PCCM) Inpatient/Outpatient
Authorization Form B-68
B.39 Primary Care Case Management (PCCM) Referral Form B-69
B.40 Primary Care Case Management (PCCM) Pre-Contractual/Recredentialing Site and Medical Record Evaluation B-70
B.41 Physician's Examination Report B-71
B.42 Physician's Medical Necessity Certification for Nonemergency Ambulance Transports (Texas Medicaid Program) B-72
B.43 Private Pay Agreement B-73
B.44 Provider Information Change Form Instructions B-74
B.45 Provider Information Change Form B-75
B.46 Psychiatric Inpatient Initial Admission Request Form B-76
B.47 Psychiatric Inpatient Extended Stay Request Form B-77
B.48 Pulse Oximeter Form B-78
B.49 Radiology Prior Authorization Request Form B-79
B.50 Request for Initial Outpatient Therapy (Form TP-1) B-80
B.51 Request for Extension of Outpatient Therapy (2 Pages) (Form TP-2) B-81
B.52 Request for Extended Outpatient Psychotherapy/Counseling Form B-83
B.53 Sample Letter - XUB Computer Billing Service Inc. B-84
B.54 Specimen Submission Form G-1C, Maternal Serum Prenatal Triple Screen, Instructions B-85
B.55 Specimen Submission Form G-1C, Maternal Serum Prenatal Triple Screen B-86
B.56 Specimen Submission Form G-1C, Maternal Serum Prenatal Triple Screen, Spanish Instructions (2 Pages) B-87
B.57 Specimen Submission Form G-1C, Maternal Serum Prenatal Triple Screen (Spanish, 2 Pages) B-89
B.58 Statement for Initial Wound Therapy System In-Home Use (2 Pages) B-91
B.59 Statement for Recertification of Wound Therapy System In-Home Use B-93
B.60 Sterilization Consent Form Instructions (2 Pages) B-94
B.61 Sterilization Consent Form (English) B-96
B.62 Sterilization Consent Form (Spanish) B-97
B.63 Texas Medicaid Palivizumab (Synagis) Prior Authorization Request Form B-98
B.64 Texas Medicaid Vendor Drug Program Palivizumab (Synagis) Prescription Form B-99
B.65 Electronic Remittance and Status (ER&S) Agreement (2 Pages) B-100
B.66 Texas Medicaid Prior Authorization Request Form: Intrathecal Baclofen or Morphine Pump Sections I and II (2 Pages) B-102
B.67 Texas Medicaid Refund Information Form B-104
B.68 THSteps-CCP Prior Authorization Request Form B-105
B.69 THSteps-CCP Prior Authorization Private Duty Nursing 4 or 6 Month Authorization B-106
B.70 THSteps-CCP ECI Request for Initial/Renewal Outpatient Therapy B-107
B.71 THSteps Dental Mandatory Prior Authorization Request Form B-108
B.72 THSteps Dental Criteria for Dental Therapy Under General Anesthesia (2 Pages) B-109
B.73 THSteps Referral Form Instructions B-111
B.74 THSteps Referral Form B-112
B.75 Tort Response Form B-113
B.76 Ventilator Service Agreement B-114
B.77 Vision Care Eyeglass Patient (Medicaid Client) Certification Form B-115
B.78 Vision Care Eyeglass Patient (Medicaid Client) Certification Form (Spanish) B-116
B.79 Wheelchair/Scooter/Stroller Seating Assessment Form (THSteps-CCP/Home Health Services) (Next 6 Pages) B-117
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