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Claim Form Examples

Last updated on 11/5/2021

The following are examples of completed claim forms needed by Texas Medicaid providers. The forms are grouped by handbook to make locating the correct example easier.

Ambulance Services Handbook

Behavioral Health, Rehabilitation, and Case Management Services Handbook

Certified Respiratory Care Practitioner (CRCP) Services Handbook

Children's Services Handbook

Clinics and Other Outpatient Facility Services Handbook

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook

Gynecological and Reproductive Health and Family Planning Services Handbook

Home Health Nursing and Private Duty Nursing Services Handbook

Inpatient and Outpatient Hospital Services Handbook

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook


Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook

Physical Therapist (251.05 KB)

Radiology and Laboratory Services Handbook

Vision and Hearing Services Handbook

Vision Services (247.09 KB)