Family Planning Forms

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Family Planning Forms

Family Planning forms are included in the forms for Texas Medicaid. For convenience, links to the forms are duplicated below.

Current Forms

Claims Filing

Family Planning Claim Form 2017 - 3/1/2013

Legal

Sterilization-Consent-Form-Instructions - 3/10/2010

Sterilization-Consent-Form-(Spanish) - 7/1/2010

Sterilization-Consent-Form-(English) - 7/1/2010

Provider Enrollment - Forms

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

Provider Information Change Form - 4/20/2012

Provider Change of Ownership Form - 4/8/2008

Principal Information Form PIF2 - 12/17/2012

Provider Information Form PIF1 - 12/17/2012

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

Remittance and Status

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

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

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

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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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