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Heading: Providers Children with Special Health Care Needs (CSHCN) Services Program

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Forms for CSHCN Services Program Providers

The forms on this page are all of the current forms needed by CSHCN Services Program providers. The forms are grouped by type to make locating the correct for easier.

Current Forms

Authorization

Authorization and Prior Authorization Request (Generic) - 5/16/2013

Authorization Request for Apnea Monitor Rental - 5/16/2013

Authorization Request for Extension of Outpatient Therapy (TP-2) - 5/16/2013

Authorization Request for Hemophilia Blood Factor Products - 5/16/2013

Authorization Request for Initial Outpatient Therapy (TP1) - 5/16/2013

Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services and Instructions - 5/16/2013

Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face Clinician-Directed Care Coordination Services and Instructions - 5/16/2013

Certification Documentation

Criteria for Dental Therapy Under General Anesthesia - 5/18/2011

Documentation of Receipt (English) - 5/18/2011

Documentation of Receipt (Spanish) - 5/18/2011

Home Health (Skilled Nursing) Referral and Treatment Plan - 5/18/2011

Physician/Dentist Assessment Form - 4/1/2008

Physician/Dentist Assessment Form Instructions (English) - 5/18/2011

Physician/Dentist Assessment Form Instructions (Spanish) - 5/18/2011

Reimbursement Request for Transportation of the Remains of Deceased Clients - 5/18/2011

Vision Care Eyeglass Client Certification Form (English) - 5/18/2011

Vision Care Eyeglass Client Certification Form (Spanish) - 5/18/2011

Wheelchair Seating Evaluation Form - 5/18/2011

Legal

CSHCN client application - English - 2010 - 5/23/2012

CSHCN client application - Spanish - 2010 - 5/23/2012

Form to Release CSHCN Services Program Claims History (English) - 4/1/2009

Form to Release CSHCN Services Program Claims History (Spanish) - 4/1/2009

Tort Response Form - 11/19/2008

Miscellaneous

CSHCN-drug-copay-form.pdf - 7/14/2010

Prior Authorization

Durable_Medical_Equipment_(DME).pdf -

Apnea Monitor Rental Authorization - 5/16/2013

Non-emergency Ambulance Exception - 2/1/2013

Non-emergency Ambulance Prior Authorization Request - 2/1/2013

Prior Authorization and Authorization Request for Durable Medical Equipment (DME) - 5/16/2013

Prior Authorization Request for Augmentative Communication Devices - 5/16/2013

Prior Authorization Request for Chest Physiotherapy Devices Form and Instructions - 5/16/2013

Prior Authorization Request for Dental or Orthodontia Services - 5/16/2013

Prior Authorization Request for Diapers, Pull-ups, Briefs, or Liners Form and Instructions - 5/16/2013

Prior Authorization Request for External Insulin Pump - 5/19/2011

Prior Authorization Request for Hospice Services - 5/16/2013

Prior Authorization Request for Inpatient Hospital Admission—For Use by Facilities Only - 5/16/2013

Prior Authorization Request for Inpatient Psychiatric Care - 5/16/2013

Prior Authorization Request for Inpatient Rehabilitation Admission - 5/16/2013

Prior Authorization Request for Inpatient Surgery—For Surgeons Only Form and Instructions - 5/16/2013

Prior Authorization Request for Medical Foods - 5/16/2013

Prior Authorization Request for Medical Nutritional Services Form and Instructions - 5/16/2013

Prior Authorization Request for Omalizumab Form and Instructions - 5/16/2013

Prior Authorization Request for Outpatient Surgery—For Outpatient Facilities and Surgeons Form and Instructions - 5/16/2013

Prior Authorization Request for Palivizumab (Synagis) - 5/16/2013

Prior Authorization Request for Pulse Oximeter Devices Form and Instructions - 5/16/2013

Prior Authorization Request for Renal Dialysis Treatment - 5/16/2013

Prior Authorization Request for Respiratory Care—CRCP - 5/16/2013

Stem Cell or Renal Transplant - 5/16/2013

Provider Enrollment - Applications

Children with Special Health Care Needs (CSHCN) Provider Enrollment Application - 3/11/2013

CSHCN Services Program Expedited Enrollment Application - 12/20/2012

Provider Enrollment - Forms

ACA Primary Care Services Attestion Form - 3/14/2013

Disclosure of Ownership and Control Interest Statement - 12/17/2012

Principal Information Form PIF2 - 12/17/2012

Provider Change of Ownership Form - 4/8/2008

Provider Information Change Form - 4/20/2012

Provider Information Form PIF1 - 12/17/2012

Required Information for Customized Durable Medical Equipment (DME) Providers - 12/17/2010

Required Information for Enrollment as a CSHCN Services Program Dental Orthodontia Provider - 9/4/2012

Required Information for Enrollment as a CSHCN Services Program Stem Cell Transplant Facility - 9/17/2007

W9 - Request for Taxpayer Identification Number and Certification - 9/29/2011

Remittance and Status

Claim Status Inquiry Authorization (for Acute Care Providers) - 7/30/2007

CSHCN Services Program Refund Information Form - 6/1/2009

Electronic Funds Transfer (EFT) Information - 10/22/2009

Electronic Remittance and Status (ER&S) Agreement (for Acute Care Providers) - 7/30/2007

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Code Updates: Recent changes to procedure and diagnosis codes, including HCPCS and ICD-9 codes

Topics: Information of interest to providers, including NDC and Alberto N. and past initiatives such as PACT transition and hurricanes

Terms and Conditions

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