Forms

Prior Authorization

Children and Pregnant Women (CPW) Referral and Intake Form

Medicaid (STAR) and CHIP Prior Authorization Forms

Medical Record Retrieval and Electronic Medical Record Questionnaire

Private Duty Nurse (PDN) Initial Request Long Term Services and Support (LTSS) Authorization Request Checklist

Private Duty Nurse (PDN) Recertification and Revision Request Long Term Services and Support (LTSS) Authorization Request Checklist

Private Pay Agreement

Request for Prior Authorization – Acute

Request for Prior Authorizatioin - Long Term Services and Support (LTSS)

STAR Kids Prior Authorization Form

Texas Standard Prior Authorization of Health Care Services Form

Behavioral Health

Applied Behavioral Analysis Form

Applied Behavioral Health Prior Authorization Requirement Checklist

Behavioral Health Coordination of Care Form

Behavioral Health Prior Authorization Checklist

Substance Use Residential Services Form

Other

Access Appointment Availability OBGYN

Access Appointment Availability PCP

Access Appointment Availability Specialist

Attestation Form for Collaborative Care Model (CoCM) in Texas Medicaid

Claim Status Request Form

DME Request for Claim Status Form

DME Review Request Form

Migrant Farmworker Questionnaire

Outreach Request Form

Provider Appeal Request Form

Provider Compliance Challenges with Prenatal Appointment Availability

Provider Refund Form

Reconsideration Request Form