Forms
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Certificates of Medical Necessity
Certification Documentation
- DME Certification and Receipt Form (182.25 KB)
- Medicaid Vision Eyewear Client Certification Form (English) (51.48 KB)
- Medicaid Vision Eyewear Client Certification Form (Spanish) (51.3 KB)
- Physician’s Examination Report (64.39 KB)
- Texas Medicaid and CSHCN Services Program Handicapping Labio-Lingual Deviation (HLD) Index Score Sheet (55.74 KB)
Claims Filing
- Crossover Inpatient Hospital Claim Type 50 TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template (171.93 KB)
- Crossover Outpatient Facility Claim Type 31 TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template (199.28 KB)
- Crossover Professional Claim Type 30 TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template (234.85 KB)
- Informational Claims Submission Form (104.44 KB)
- Other Insurance Form (38.6 KB)
- Texas Medicaid Refund Information Form (68.92 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)
- Federally Qualified Health Center (FQHC) Affiliation Affidavit (50.28 KB)
- Hospital Report (Newborn Child or Children) (Form 7484) (80.31 KB)
- Informational Claims Submission Form (104.44 KB)
- Medical Records Declaration (136.14 KB)
- Private Pay Agreement (7.31 KB)
- Sample Letter to XUB Computer Billing, Inc. (236.33 KB)
- Sterilization Consent Form (English) (122.3 KB)
- Sterilization Consent Form (Spanish) (166.86 KB)
- Sterilization Consent Form Instructions (190.7 KB)
- Title XIX Hysterectomy Acknowledgement Form (67.04 KB)
- Tort Response Form (66.32 KB)
- Use and Release of Health Information Authorization (122.17 KB)
- Use and Release of Health Information Authorization (Spanish) (1.28 MB)
Miscellaneous
Order Forms
- Addendum to Home Health Services (Title XIX) DME/Medical Supplies Prescribing Provider Order Form (245.89 KB)
- Home Health Services (Title XIX) DME/Medical Supplies Prescribing Provider Order Form (128.86 KB)
- Home Health Services (Title XIX) DME/Medical Supplies Prescribing Provider Order Form Instructions (107.4 KB)
Prior Authorization
- Case Management for Children and Pregnant Women (CPW) Initial Prior Authorization Request (122.82 KB)
- Case Management for Children and Pregnant Women (CPW) Prior Authorization Request For Additional Visits (116.47 KB)
- CCP Prior Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services (143.59 KB)
- CCP Prior Authorization Request Form (118.75 KB)
- CCP Prior Authorization Request Form Instructions (120.03 KB)
- CRCP Prior Authorization Request Form (88.05 KB)
- Criteria for Dental Therapy Under General Anesthesia (81.96 KB)
- Donor Human Milk Request Form (80.38 KB)
- External Insulin Pump Form (78.75 KB)
- Hereditary Breast and Ovarian Cancer (HBOC) Genetic Testing (147.32 KB)
- Home Health Prior Authorization Checklist (40.23 KB)
- Home Telemonitoring Services Prior Authorization (Medicaid) (86.51 KB)
- Home Telemonitoring Services Prior Authorization Instructions (Medicaid) (89.37 KB)
- Medicaid Physical, Occupational or Speech Therapy (PT, OT, ST) Prior Authorization Form (83.41 KB)
- Medicaid Physical, Occupational or Speech Therapy (PT, OT, ST) Prior Authorization Form Instructions (196.86 KB)
- Obstetric Ultrasound Prior Authorization Request (147.39 KB)
- Obstetric Ultrasound Prior Authorization Request Instructions (75.5 KB)
- Outpatient Mental Health Services Request Form (129.35 KB)
- Outpatient Substance Use Disorder Counseling Extension Request Form (91.86 KB)
- Outpatient Withdrawal Management Authorization Request Form (138.67 KB)
- Prior Authorization Request for CPAP or RAD (Bi-level PAP) (176.92 KB)
- Prior Authorization Request for Oxygen Therapy Devices and Supplies (107.85 KB)
- Prior Authorization Request for Secretion and Mucus Clearance Devices - Initial Request (154.43 KB)
- Prior Authorization Request for Secretion and Mucus Clearance Devices - Renewal Request (125.07 KB)
- Psychiatric Inpatient Extended Stay Request Form (108.53 KB)
- Radiology Prior Authorization Request Form (77.85 KB)
- Residential Substance Use Disorder Treatment Request Form (222.93 KB)
- Residential Withdrawal Management Authorization Request Form (126.39 KB)
- Special Medical Prior Authorization (SMPA) Request Form (87.16 KB)
- Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face Clinician-Directed Care Coordination Services–CCP (45.05 KB)
- Standardized Prior Authorization Request Form for Health Care Services (1.49 MB)
- Texas Health Steps Dental Mandatory Prior Authorization Request Form (262.47 KB)
- Texas Medicaid and CSHCN Services Program Non-emergency Ambulance Exception Prior Authorization Request (108.86 KB)
- Texas Medicaid and CSHCN Services Program Non-emergency Ambulance Prior Authorization Request (183.25 KB)
- Wound Care Equipment and Supplies Order Form (196.62 KB)
Private Duty Nursing, Prescribed Pediatric Extended Care Centers, and Skilled Nursing Prior Authorization Forms
- Home Health Plan of Care (POC) (112.74 KB)
- Home Health Plan of Care (POC) Instructions (56.42 KB)
- Instructions for Completing Prescribed Pediatric Extended Care Center Prior Authorization Forms (476.07 KB)
- Instructions for Completing Private Duty Nursing Prior Authorization Forms (103.42 KB)
- Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers (581.45 KB)
- Prescribed Pediatric Extended Care Center (PPECC) Plan of Care (397.4 KB)
- Prescribed Pediatric Extended Care Center (PPECC) Plan of Care Instructions (152.8 KB)
- Private Duty Nursing (CCP Prior Authorization) 6 Month Authorization (73.26 KB)
- Private Duty Nursing Prior Authorization Form Packet (906.26 KB)
Private Duty Nursing 24 Hour Flowsheet Examples
Provider Enrollment - Forms
Remittance and Claim Status Forms
- Claim Status Inquiry Authorization for Acute Care Providers (287.9 KB)
- Electronic Remittance Advice Agreement (289.31 KB)
- Texas Medicaid Group Volume Consent Form (85.15 KB)