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
Transportation Benefit 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
LifeTimes Newsletter
Fall 2022
Summer 2022
Spring 2022
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 the Customer Advocate Department at 1-888-657-6061 (TTY 711) to request a copy.