Forms
To locate a specific form, type the title or a keyword in the Title field below. Use the Programs, Topics, and Categories drop down options to further narrow your results.
Authorization
Authorization/Prior Authorization
- CSHCN Services Program Authorization and Prior Authorization Request for Cardiorespiratory Monitor (CRM) Form and Instructions (203.3 KB)
- CSHCN Services Program Authorization and Prior Authorization Request for Durable Medical Equipment (DME) Form and Instructions (219.49 KB)
- CSHCN Services Program Authorization and Prior Authorization Request for Hemophilia Blood Factor Products Form and Instructions (109.66 KB)
- CSHCN Services Program Request for Authorization and Prior Authorization Request Form and Instructions (91.48 KB)
Certification Documentation
- CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia (112.13 KB)
- CSHCN Services Program Home Health Skilled Nursing Request and Plan of Care Form and Instructions (182.35 KB)
- CSHCN Services Program Wheelchair Seating Evaluation Form (224.59 KB)
- Documentation of Receipt (English) (62.2 KB)
- Documentation of Receipt (Spanish) (56.36 KB)
- Physician/Dentist Assessment Form (117.5 KB)
- Reimbursement Request for Transportation of the Remains of Deceased Clients (41.29 KB)
- Texas Medicaid and CSHCN Services Program Handicapping Labio-Lingual Deviation (HLD) Index Score Sheet (46 KB)
- Vision Care Eyeglass Client Certification Form (86.64 KB)
- Vision Care Eyeglass Client Certification Form (Spanish) (89.36 KB)
Legal
- Abortion Certification Statements Form (16.75 KB)
- Authorization to Release Confidential Information (73.64 KB)
- Authorization to Release Confidential Information (Spanish) (138.24 KB)
- Business Records Affidavit (68.32 KB)
- Child Abuse Reporting Guidelines (18 KB)
- Child Abuse Reporting Guidelines--Checklist for HHSC Monitoring (16.96 KB)
- Children with Special Health Care Needs (CSHCN) Services Program Client Application (English) (1.37 MB)
- Children with Special Health Care Needs (CSHCN) Services Program Client Application (Spanish) (816.35 KB)
- CSHCN IPPA Certification Form (63.75 KB)
- Form to Release CSHCN Services Program Claims History (English) (43.26 KB)
- Form to Release CSHCN Services Program Claims History (Spanish) (43.26 KB)
- Tort Response Form (66.32 KB)
Miscellaneous
- Credit Balance Refund Worksheet (385.53 KB)
- CSHCN Drug Copay Form (92.29 KB)
Prior Authorization
- CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia (112.13 KB)
- CSHCN Services Program Genetic Testing for Hereditary Breast and/or Ovarian Cancer Prior Authorization Form (170.02 KB)
- CSHCN Services Program Home Telemonitoring Services Prior Authorization Request (68.08 KB)
- CSHCN Services Program Prescribed Pediatric Extended Care (PPECC) Services Prior Authorization Request Form and Instructions (227.77 KB)
- CSHCN Services Program Prior Authorization Request for Augmentative Communication Devices (95.89 KB)
- CSHCN Services Program Prior Authorization Request for CPAP or RAD (271.49 KB)
- CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services (114.1 KB)
- CSHCN Services Program Prior Authorization Request for Diabetic Equipment and Supplies Form (218.36 KB)
- CSHCN Services Program Prior Authorization Request for Diapers, Pull-ups, Briefs, or Liners Form and Instructions (110.82 KB)
- CSHCN Services Program Prior Authorization Request for Extension of Outpatient Therapy (TP2) Form and Instructions (123.88 KB)
- CSHCN Services Program Prior Authorization Request for Hospice Services (104.62 KB)
- CSHCN Services Program Prior Authorization Request for Initial Outpatient Therapy (TP1) Form and Instructions (81.8 KB)
- CSHCN Services Program Prior Authorization Request for Inpatient Hospital Admission—For Use by Facilities Only Instructions (108.22 KB)
- CSHCN Services Program Prior Authorization Request for Inpatient Psychiatric Care Form and Instructions (83.99 KB)
- CSHCN Services Program Prior Authorization Request for Inpatient Rehabilitation Admission Form and Instructions (137.12 KB)
- CSHCN Services Program Prior Authorization Request for Inpatient Surgery Form and Instructions - For Surgeons Only (104.54 KB)
- CSHCN Services Program Prior Authorization Request for Medical Foods Form and Instructions (114.01 KB)
- CSHCN Services Program Prior Authorization Request for Medical Nutritional Services Form and Instructions (110.72 KB)
- CSHCN Services Program Prior Authorization Request for Outpatient Surgery - For Outpatient Facilities and Surgeons (100.54 KB)
- CSHCN Services Program Prior Authorization Request for Oxygen Therapy Form and Instructions (201.87 KB)
- CSHCN Services Program Prior Authorization Request for Pulse Oximeter Form and Instructions (159.43 KB)
- CSHCN Services Program Prior Authorization Request for Renal Dialysis Treatment (108.29 KB)
- CSHCN Services Program Prior Authorization Request for Respiratory Care CRCP (93.29 KB)
- CSHCN Services Program Prior Authorization Request for Secretion and Mucus Clearance Devices Form and Instructions (210.16 KB)
- CSHCN Services Program Prior Authorization Request for Stem Cell or Renal Transplant (99.45 KB)
- Texas Medicaid and CSHCN Services Program Non-emergency Ambulance Exception Prior Authorization Request (122.33 KB)
- Texas Medicaid and CSHCN Services Program Non-emergency Ambulance Prior Authorization Request (218.52 KB)
Provider Enrollment - Applications
Provider Enrollment - Forms
- Corporate Board of Directors Resolution (65.89 KB)
- CSHCN Services Program Identification Form (70.01 KB)
- Disclosure of Ownership and Control Interest Statement (85.13 KB)
- Electronic Funds Transfer (EFT) Notification (148.2 KB)
- HHSC Provider Agreement for Participation in the CSHCN Services Program (120.67 KB)
- Principal Information Form (PIF2) (82.46 KB)
- Provider Change of Ownership Form (126.92 KB)
- Provider Information Change Form (104.67 KB)
- Provider Information Form (PIF1) (89.99 KB)
- Required Information for Customized Durable Medical Equipment (DME) Providers (31.72 KB)
- Required Information for Enrollment as a CSHCN Services Program Dental / Orthodontia Provider (99.81 KB)
Remittance and Status
- Claim Status Inquiry Authorization for Acute Care Providers (169.44 KB)
- Credit Balance Refund Worksheet (385.53 KB)
- CSHCN Services Program Refund Information Form (36.82 KB)
- Electronic Remittance Advice Agreement (309.38 KB)