Forms and Documents

These forms and documents are available as PDF files. Just click on a form or document to download it. You will need Adobe Reader to view these files; this can be downloaded free of charge at Adobe's site.

If you would like to have a printed copy of our member handbook, provider directory or other materials that will help you better understand your benefits, please call Customer Service. Your request will be fulfilled at no cost within five business days.

Handbooks and Directories

CHIP and CHIP Perinatal Member Handbook
Provider Directory
Pharmacy Directory
Drug List (Formulary)
Dental Provider Directory (adult CHIP Perinate members only)
Benefit Reference Guide

Forms

Appeal Request Form
Complaint Form
Prenatal Incentive Options (Car Seat or Pack and Play) Form
Primary Care Provider (PCP) Selection Form
Request to Access PHI Form
Text and Email Messages Permission Form

Value-Added Services and Program Brochures

Value-Added Services Brochure
Logisticare Transportation Brochure
CHIP Care Coordination Brochure
Special Beginnings Brochure
Medicaid STAR and CHIP Resource Guide
Value-Added Dental Services

Evidence of Coverage Schedule

Evidence of Coverage
CHIP Schedule of Benefits, Excluded Services and Covered Health Services A
CHIP Schedule of Benefits, Excluded Services and Covered Health Services B
CHIP Schedule of Benefits, Excluded Services and Covered Health Services C
CHIP Schedule of Benefits, Excluded Services and Covered Health Services D

Important Notices

Annual Notices and CAHPS Survey Results
Health Assessment Questionnaire
HIPAA Notice of Privacy Practices
Preventive Health Guidelines*
Your Rights for Appeal of an Adverse Determination

Find additional prescription drug forms here.

Additional Resources

Texas Health and Human Services Commission
Texas Department of State Health Services
Texas Department of Family and Protective Services
Texas Department of State Health Services, Women, Infants, and Children Program (WIC)
Texas Juvenile Justice Department
Children Advocacy Centers of Texas, Inc.
Your Texas Benefits (from the Texas Health and Human Services Commission)
Healthy Texas Women

* In addition to the preventive health guidelines, clinical guidelines are available upon request. Call customer service at 1-888-657-6061 (TTY 711) to request a copy.
 

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Contact Us

  • 1-888-657-6061 (TTY 711)
  • 8 a.m. to 8 p.m. Central Time Monday through Friday
  • Contact Us