Health Care Provider Forms

Note: Unless otherwise indicated, PRINT the document and submit as indicated on the form.

Medical Policy Forms (Note: May be used as a supplement to medical record documentation)

Form Title

Description

Bariatric Surgery

Interactive

Cranial Remolding Orthosis (CRO) Device

Interactive

Genetic Testing

Instructions
Fillable

Hyperbaric Oxygen (HBO) Pressurization

Interactive

Oncotype DX

Interactive

Varicose Vein Management

Interactive

Wheelchair Medical Necessity and Home Evaluation Verification

Interactive

Behavioral Health/Mental Health Forms for ERS Participants

Form Title

Description

Mental Health Forms for Employee Retirement System of Texas (ERS)

Select Link for list of forms

Behavioral Health/Mental Health Forms for TRSParticipants

Form Title

Description

Behavioral Health Forms for Teacher Retirement System of Texas (TRS)

Select Link for list of forms

Pharmacy

Form Title

Description

Express Scripts® Pharmacy Mail Order: ePrescribe new prescriptions to EXPRESS SCRIPTS HOME DELIVERY or call 888-327-9791 for faxing instructions

Fax forms must be faxed from a physician's office

Accredo Specialty Pharmacy General Use Fax Form

Specialty pharmacy drugs fax form for general use

Accredo Specialty Pharmacy Referral Forms by Therapy

Specialty pharmacy drugs fax form by drug therapy

 

Prior Authorization Standard Prescription Drugs

Fillable

Quantity Limit Override Request

Request to override the dispensing/quantity limit

Topical Verapamil Override Request Specialty pharmacy drugs fax form for general use