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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-38
B.12 DME Certification and Receipt Form B-39
B.13 Donor Human Milk Request Form B-42
B.14 Electronic Funds Transfer (EFT) Information B-43
B.15 Electronic Funds Transfer (EFT) Authorization Agreement B-44
B.16 External Insulin Pump B-45
B.17 Federally Qualified Health Center Report (Newborn Child or Children) (Form 7484) B-46
B.18 Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) B-47
B.19 Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form
Instructions (2 Pages) B-48
B.20 Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical
Supplies Physician Order Form B-50
B.21 Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician
Order Form B-51
B.22 Home Health Services Plan of Care (POC) Instructions B-52
B.23 Home Health Services Plan of Care (POC) B-53
B.24 Home Health Services Prior Authorization Checklist B-54
B.25 Hospital Report (Newborn Child or Children) (Form 7484) B-55
B.26 Hysterectomy Acknowledgment Form B-56
B.27 Informational Inquiry Form B-57
B.28 Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device Form-
Initial Request B-58
B.29 Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device Form-
Extended Request B-59
B.30 Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy B-60
B.31 Medicaid Certificate of Medical Necessity for Reduction Mammaplasty B-61
B.32 Medicaid Certificate of Medical Necessity for In-Home Total Parenteral
Nutrition (TPN) B-62
B.33 Nursing Addendum to Plan of Care (THSteps-CCP) (7 Pages) B-63
B.34 Other Insurance Form B-70
B.35 Primary Care Case Management (PCCM) Behavioral Health Consent Form B-71
B.36 Primary Care Case Management (PCCM) Behavioral Health Consent Form (Spanish) B-72
B.37 Primary Care Case Management (PCCM) Community Health Services
Referral Request Form B-73
B.38 Primary Care Case Management (PCCM) Inpatient/Outpatient Authorization Form B-74
B.39 Primary Care Case Management (PCCM) Referral Form B-75
B.40 Primary Care Case Management (PCCM) Pre-Contractual/Recredentialing Site and
Medical Record Evaluation B-76
B.41 Physician's Examination Report B-77
B.42 Physician's Medical Necessity Certification for Nonemergency Ambulance
Transports (Texas Medicaid Program) B-78
B.43 Private Pay Agreement B-79
B.44 Provider Information Change Form Instructions B-80
B.45 Provider Information Change Form B-81
B.46 Psychiatric Inpatient Initial Admission Request Form B-82
B.47 Psychiatric Inpatient Extended Stay Request Form B-83
B.48 Pulse Oximeter Form B-84
B.49 Radiology Prior Authorization Request Form B-85
B.50 Request for Initial Outpatient Therapy (Form TP-1) B-86
B.51 Request for Extension of Outpatient Therapy (Form TP-2) (2 Pages) B-87
B.52 Request for Extended Outpatient Psychotherapy/Counseling Form B-89
B.53 Sample Letter -XUB Computer Billing Service Inc. B-90
B.54 Specimen Submission Form G-1C, Maternal Serum Prenatal Triple Screen,
Instructions B-91
B.55 Specimen Submission Form G-1C, Maternal Serum Prenatal Triple Screen B-92
B.56 Specimen Submission Form G-1C, Maternal Serum Prenatal Triple Screen
(Spanish, 2 Pages) B-93
B.57 Statement for Initial Wound Therapy System In-Home Use (2 Pages) B-95
B.58 Statement for Recertification of Wound Therapy System In-Home Use B-97
B.59 Sterilization Consent Form Instructions (2 Pages) B-98
B.60 Sterilization Consent Form (English) B-100
B.61 Sterilization Consent Form (Spanish) B-101
B.62 Authorization for Use and Release of Health Information B-102
B.63 Texas Medicaid Palivizumab (Synagis) Prior Authorization Request Form B-103
B.64 Texas Medicaid Vendor Drug Program Palivizumab (Synagis) Prescription Form B-104
B.65 Electronic Remittance and Status (ER&S) Agreement (2 Pages) B-105
B.66 Texas Medicaid Refund Information Form B-107
B.67 THSteps-CCP Prior Authorization Request Form B-108
B.68 THSteps-CCP Prior Authorization Private Duty Nursing 4 or 6 Month Authorization B-109
B.69 THSteps-CCP ECI Request for Initial/Renewal Outpatient Therapy B-110
B.70 THSteps Dental Mandatory Prior Authorization Request Form B-111
B.71 THSteps Dental Criteria for Dental Therapy Under General Anesthesia (2 Pages) B-112
B.72 THSteps Referral Form Instructions B-114
B.73 THSteps Referral Form B-115
B.74 Tort Response Form B-116
B.75 Ventilator Service Agreement B-117
B.76 Vision Care Eyeglass Patient (Medicaid Client) Certification Form B-118
B.77 Vision Care Eyeglass Patient (Medicaid Client) Certification Form (Spanish) B-119
B.78 Wheelchair/Scooter/Stroller Seating Assessment Form (THSteps-CCP/Home
Health Services) (Next 6 Pages) B-120
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