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)
Certificates of Medical Necessity
Certification Documentation
Order Forms
Prior Authorization
- CCP Prior Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services (104.07 KB)
- CCP Prior Authorization Request Form (105.27 KB)
- CCP Prior Authorization Request Form Instructions (111.38 KB)
- CRCP Prior Authorization Request Form (79.52 KB)
- Criteria for Dental Therapy Under General Anesthesia (68.48 KB)
- 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)
- Donor Human Milk Request Form (78.76 KB)
- External Insulin Pump Form (76.76 KB)
- Hereditary Breast and Ovarian Cancer (HBOC) Genetic Testing (116.28 KB)
- Home Health Prior Authorization Checklist (40.23 KB)
- Home Telemonitoring Services Prior Authorization (Medicaid) (826.21 KB)
- Home Telemonitoring Services Prior Authorization Instructions (Medicaid) (591.76 KB)
- Medicaid Physical, Occupational or Speech Therapy (PT, OT, ST) Prior Authorization Form (191 KB)
- Medicaid Physical, Occupational or Speech Therapy (PT, OT, ST) Prior Authorization Form Instructions (105.3 KB)
- Obstetric Ultrasound Prior Authorization Request (98.8 KB)
- Obstetric Ultrasound Prior Authorization Request Instructions (36.11 KB)
- Outpatient Mental Health Services Request Form (149.89 KB)
- Outpatient Substance Use Disorder Counseling Extension Request Form (124.98 KB)
- Outpatient Withdrawal Management Authorization Request Form (183.52 KB)
- Prior Authorization Request for CPAP or RAD (Bi-level PAP) (209.48 KB)
- Prior Authorization Request for Oxygen Therapy Devices and Supplies (104.98 KB)
- Prior Authorization Request for Secretion and Mucus Clearance Devices - Initial Request (185.54 KB)
- Prior Authorization Request for Secretion and Mucus Clearance Devices - Renewal Request (154.99 KB)
- Psychiatric Inpatient Extended Stay Request Form (67.36 KB)
- Residential Substance Use Disorder Treatment Request Form (422.25 KB)
- Residential Withdrawal Management Authorization Request Form (169.67 KB)
- Special Medical Prior Authorization (SMPA) Request Form (65.48 KB)
- Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face Clinician-Directed Care Coordination Services–CCP (20.29 KB)
- Standardized Prior Authorization Request Form for Health Care Services (1.49 MB)
- Texas Health Steps Dental Mandatory Prior Authorization Request Form (229.5 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)
- Wound Care Equipment and Supplies Order Form (204.12 KB)
Private Duty Nursing, Prescribed Pediatric Extended Care Centers, and Skilled Nursing Prior Authorization Forms
- Home Health Plan of Care (POC) (141.3 KB)
- Home Health Plan of Care (POC) Instructions (96.3 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 (237.87 KB)
- Prescribed Pediatric Extended Care Center (PPECC) Plan of Care (142.02 KB)
- Prescribed Pediatric Extended Care Center (PPECC) Plan of Care Instructions (103.14 KB)
- Private Duty Nursing (CCP Prior Authorization) 6 Month Authorization (67.59 KB)
- Private Duty Nursing Prior Authorization Form Packet (478.09 KB)