Forms for Medicaid Providers

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Forms for Medicaid Providers

The forms on this page are all of the current forms needed by Texas Medicaid providers. The forms are grouped by type to make locating the correct form easier.

Current Forms

Certificates of Medical Necessity

Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device Form—Extended Request - 1/1/2009

Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device Form—Initial Request - 1/1/2009

Medicaid Certificate of Medical Necessity for CPAP/BIPAP or Oxygen Therapy Form - 8/6/2007

Medicaid Certificate of Medical Necessity for Reduction Mammaplasty - 7/30/2007

Wound Therapy System In-Home Use (Recertification) - 12/31/2010

Wound Therapy System In-Home Use, (Initial) - 12/31/2010

Certification Documentation

DME Certification and Receipt Form - 7/15/2011

Physician’s Examination Report - 5/17/2013

Ventilator Service Agreement - 1/15/2008

Vision Care Eyeglass Patient (Medicaid Client) Certification Form (English) - 1/15/2008

Vision Care Eyeglass Patient (Medicaid Client) Certification Form (Spanish) - 1/15/2008

Claims Filing

Family Planning Claim Form 2017 - 3/1/2013

MRAN Form Crossover Claim Type 30 Form and Instructions - 1/18/2012

MRAN Form Crossover Claim Type 31 Form and Instructions - 1/18/2012

MRAN Form Crossover Claim Type 50 Form and Instructions - 1/1/2012

Other Insurance Form - 1/1/2009

Legal

Authorization for Use and Release of Health Information - 8/1/2003

Authorization for Use and Release of Health Information (Spanish) - 5/26/2011

Authorization to Release Confidential Information - English - 7/29/2009

Authorization to Release Confidential Information - Spanish - 7/29/2009

Community and Migrant Health Center Affiliation Affidavit - 11/29/2011

Community and Migrant Health Center Affiliation Checklist - 11/29/2011

Hysterectomy Acknowledgement Form - 4/24/2009

Informational Claims Submission Form - 2/22/2010

Private Pay Agreement - 1/1/2008

Sample Letter to XUB Computer Billing - 1/15/2008

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

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

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

Tort Response Form - 11/19/2008

Miscellaneous

Hearing Evaluation and Fitting and Dispensing Report - 12/2/2008

Texas Health Steps Periodicity Schedule (on DSHS website) - 3/6/2012

Wheelchair/Scooter/Stroller Seating Assessment Form (CCP/Home Health) -

Order Forms

Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form - 5/22/2013

Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Instructions - 5/22/2013

Home Health XIX Order Form Addendum - 5/22/2013

Vendor Drug Program Palivizumab (Synagis) Prescription Form - 8/21/2012

Prior Authorization

Ambulatory (Outpatient) Detoxification Authorization Request Form - 5/17/2013

Ambulatory Outpatient Substance Abuse Counseling Extension Request Form - 5/17/2013

CCP Prior Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services - 4/7/2010

CCP Prior Authorization Request Form - 5/31/2011

CCP Prior Authorization Request Form Instructions -

CRCP Prior Authorization Request Form - 5/17/2013

Criteria for Dental Therapy Under General Anesthesia - 1/1/2009

Dental Mandatory Prior Authorization Request Form (THSteps) - 3/1/2012

Donor Human Milk Request Form - 4/7/2010

External Insulin Pump Form - 7/1/2011

Home Health Prior Authorization Checklist - 6/12/2012

Intrathecal Baclofen or Morphine Pump - 7/30/2007

Non-emergency Ambulance Exception - 2/1/2013

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

Obstetric Ultrasound Prior Authorization Request - 5/23/2010

Obstetric Ultrasound Prior Authorization Request Instructions - 4/20/2011

Outpatient Psychotherapy Counseling Request Form - 1/1/2010

Outpatient Therapy, Request for Extension of (TP-2) - 7/30/2007

Outpatient Therapy, Request for Initial (TP-1) - 7/30/2007

Palivizumab (Synagis) Prior Authorization Request - 7/19/2012

Private Duty Nursing (CCP Prior Authorization) 6 Month Authorization - 5/16/2012

Psychiatric Inpatient Extended Stay Request Form - 5/17/2013

Psychiatric Inpatient Initial Admission Request Form - 5/17/2013

Psychological and Neurological Testing Request - 1/1/2010

Pulse Oximeter Form - 5/25/2012

Radiology Prior Authorization Request Form - 2/1/2010

Residential Detoxification Authorization Request Form - 11/12/2010

Residential Substance Abuse Treatment Authorization Request Form - 5/17/2013

Special Medical Prior Authorization (SMPA) Request Form - 5/17/2013

Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face Clinician-Directed Care Coordination Services–CCP - 10/24/2008

Private Duty Nursing, Plan of Care, and Examples

Home Health Plan of Care (POC) - 2/23/2011

Home Health Plan of Care (POC) Instructions - 2/23/2011

Private Duty Nursing Prior Authorization Forms - 4/20/2012

Sample 24-Hour Daily Flow Sheet - 120 Hours per Week -

Sample 24-Hour Daily Flow Sheet - 50 Hours per Week -

Sample 24-Hour Daily Flow Sheet - 80 Hours per Week -

Provider Enrollment - Applications

Texas Health Steps Provider Enrollment Application - 12/17/2012

Texas Medicaid Provider Enrollment Application - 5/15/2013

Texas Medicaid Provider Enrollment Application for Ordering and Referring Providers Only - 3/11/2013

Texas Medicaid Provider Enrollment Application_ACA Addendum - 12/17/2012

Texas Vaccines for Children (TVFC) Provider Enrollment Application (on DSHS website) - 6/27/2012

THSteps Dental Provider Enrollment Application - 5/15/2013

Provider Enrollment - Forms

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

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

HHSC Medicaid Provider Agreement - 12/17/2012

Physician’s Letter of Agreement - 12/7/2012

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

Texas Medicaid Provider Surety Bond and Instructions - 4/9/2013

TMHP Consulting Agreement for Pediatrics - 3/27/2009

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

Provider Enrollment Application Walkthrough

Pharmacy Group Walkthrough - 5/25/2011

Remittance and Status

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

Credit Balance Refund Worksheet - 7/30/2007

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

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

Refund Information Form - 10/8/2012

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

Texas Women's Health Program: Click here for information

The Affordable Care Act is coming. Click here for more information on the Affordable Care Act and how it affects you.

HHSC IMPROVE. Where Texas Medicaid providers can submit concerns and suggestions. Click here to go to site.

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