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 (156.37 KB)
- CSHCN Services Program Authorization and Prior Authorization Request for Durable Medical Equipment (DME) Form and Instructions (316.6 KB)
- CSHCN Services Program Authorization and Prior Authorization Request for Hemophilia Blood Factor Products Form and Instructions (99.53 KB)
- CSHCN Services Program Request for Authorization and Prior Authorization Request Form and Instructions (102.98 KB)
Certificates of Medical Necessity
Certification Documentation
- CSHCN Services Program Home Health Skilled Nursing Request and Plan of Care Form and Instructions (244.96 KB)
- CSHCN Services Program Wheelchair Seating Evaluation Form (403.86 KB)
- DME Certification and Receipt Form (182.25 KB)
- Documentation of Receipt (English) (62.2 KB)
- Documentation of Receipt (Spanish) (56.36 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)
- 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 (55.74 KB)
- Vision Care Eyeglass Client Certification Form (50.29 KB)
- Vision Care Eyeglass Client Certification Form (Spanish) (52.74 KB)
Claims Filing
- 2017 Claim Form (372.98 KB)
- 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)
Community Waiver Programs
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 (171.26 KB)
- Federally Qualified Health Center (FQHC) Affiliation Affidavit (50.28 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)
- 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
- CSHCN Drug Copay Form (92.29 KB)
- Hearing Evaluation and Fitting and Dispensing Report (20.84 KB)
- Office of the Inspector General Utilization Review Provider Cover Sheet (53.19 KB)
- Texas Health Steps Referral Form (24.55 KB)
- Texas Health Steps Referral Form Instructions (24.78 KB)
Nursing Facility
- LTCMI 3.0 - Nursing Facility (230.19 KB)
- LTCMI 3.0 - Nursing Facility Instructions (186.83 KB)
- PASRR Comprehensive Service Plan (PCSP) Form (604.83 KB)
- PASRR Evaluation Form (2.29 MB)
- PASRR Level 1 Screening Form (678.89 KB)
- PASRR NF Specialized Service (NFSS) - Authorization Request for CMWC (208.71 KB)
- PASRR NF Specialized Service (NFSS) - Authorization Request for DME (495.82 KB)
- PASRR NF Specialized Service (NFSS) - Authorization Request for Habilitative Therapies (196.13 KB)
- PASRR NF Specialized Service (NFSS) - CMWC Supplier Acknowledgment and Signature Page (133.78 KB)
- PASRR NF Specialized Service (NFSS) - CMWC/DME Receipt Certification (119.08 KB)
- PASRR NF Specialized Service (NFSS) - CMWC/DME Signature Page (132.36 KB)
- PASRR NF Specialized Service (NFSS) - DME Supplier Acknowledgment and Signature Page (156.11 KB)
- PASRR NF Specialized Service (NFSS) - Fax Cover Sheet (214.5 KB)
- PASRR NF Specialized Service (NFSS) - Therapy Signature Page (127.98 KB)
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)
- CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia (95.54 KB)
- CSHCN Services Program Genetic Testing for Hereditary Breast and/or Ovarian Cancer Prior Authorization Form (161.39 KB)
- CSHCN Services Program Home Telemonitoring Services Prior Authorization Request (96.71 KB)
- CSHCN Services Program Prescribed Pediatric Extended Care (PPECC) Services Prior Authorization Request Form and Instructions (374.79 KB)
- CSHCN Services Program Prior Authorization Request for Augmentative Communication Devices (132.5 KB)
- CSHCN Services Program Prior Authorization Request for CPAP or RAD (356.84 KB)
- CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services (189.98 KB)
- CSHCN Services Program Prior Authorization Request for Diabetic Equipment and Supplies Form (193.7 KB)
- CSHCN Services Program Prior Authorization Request for Diapers, Pull-ups, Briefs, or Liners Form and Instructions (215.36 KB)
- CSHCN Services Program Prior Authorization Request for Extension of Outpatient Therapy (TP2) Form and Instructions (250.08 KB)
- CSHCN Services Program Prior Authorization Request for Hospice Services (151.96 KB)
- CSHCN Services Program Prior Authorization Request for Initial Outpatient Therapy (TP1) Form and Instructions (195.5 KB)
- CSHCN Services Program Prior Authorization Request for Inpatient Hospital Admission—For Use by Facilities Only Instructions (186.69 KB)
- CSHCN Services Program Prior Authorization Request for Inpatient Psychiatric Care Form and Instructions (162.51 KB)
- CSHCN Services Program Prior Authorization Request for Inpatient Rehabilitation Admission Form and Instructions (269.54 KB)
- CSHCN Services Program Prior Authorization Request for Inpatient Surgery Form and Instructions - For Surgeons Only (171.18 KB)
- CSHCN Services Program Prior Authorization Request for Medical Foods Form and Instructions (138.6 KB)
- CSHCN Services Program Prior Authorization Request for Medical Nutritional Products Form and Instructions (135.59 KB)
- CSHCN Services Program Prior Authorization Request for Outpatient Surgery - For Outpatient Facilities and Surgeons (171.16 KB)
- CSHCN Services Program Prior Authorization Request for Oxygen Therapy Form and Instructions (307.45 KB)
- CSHCN Services Program Prior Authorization Request for Pulse Oximeter Form and Instructions (231.85 KB)
- CSHCN Services Program Prior Authorization Request for Renal Dialysis Treatment (165.33 KB)
- CSHCN Services Program Prior Authorization Request for Respiratory Care CRCP (177.23 KB)
- CSHCN Services Program Prior Authorization Request for Secretion and Mucus Clearance Devices Form and Instructions (259.04 KB)
- CSHCN Services Program Prior Authorization Request for Stem Cell or Renal Transplant (194.12 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)
- CSHCN Services Program Refund Information Form (63.61 KB)
- Electronic Remittance Advice Agreement (289.31 KB)
- Submitter ID Linking Form for Long Term Care Providers (169.97 KB)
- Texas Medicaid Group Volume Consent Form (85.15 KB)
Agreements and Applications
Portal Forms
- TMHP Portal Request Change Form (129.43 KB)