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 .

Handbooks and Directories

If you need 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 within five business days.

• 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 Schedules

• 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 7-1-1) to request a copy.