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

• 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 
• Postpartum Incentive Gift Card Form 
• Prenatal Incentive Gift Card Form 
• Prenatal Incentive Options (Car Seat or Pack and Play) Form 
• Primary Care Provider (PCP) Selection Form 
• Request to Access PHI Form 
• Safety Booster Seat Form 
• Well-child Checkup Form for Infants 
• Well-child Checkup Form for Children 2+ 
• Well-child Checkup Form for Teens 
• 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 
• CHIP Schedule of Benefits, Excluded Services and Covered Health Services E 

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) 

* 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.