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Forms

Prior Authorization

Children and Pregnant Women (CPW) Referral and Intake Form

Medicaid (STAR) and CHIP Prior Authorization Forms

Private Pay Agreement

Request for Prior Authorization – Acute

Request for Prior Authorization – Long Term Services and Support (LTSS) 

LTSS Authorization Request Checklist

STAR Kids Prior Authorization Form

Texas Standard Prior Authorization of Health Care 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

Fraud Referral

Migrant Farmworker Questionnaire

Outreach Request Form

Provider Appeal Request Form

Provider Compliance Challenges with Prenatal Appointment Availability

Provider Refund Form

Rate Enhancement for Attendant Compensation Form

Reconsideration Request Form

Sports and Camp Physical Reimbursement Form

 
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  • Home
  • Network Participation
    • Network Participation
    • Attestation and Agreement
    • Credentialing and Recredentialing
    • Provider and Pharmacy Directories
  • Claims & Eligibility
    • Claims
    • Eligibility
    • Utilization Management (Prior Authorizations)
    • Long Term Services and Support (LTSS)
    • Provider Administered Drugs
    • Referral Requirements
    • STAR Kids Referral and Authorization Process
    • Electronic & Paper Submission Edits
  • Education & Reference
    • Education and Reference
    • Blue Review
    • Education Materials
    • Electronic Visit Verification (EVV)
    • Forms
    • News
    • Provider Training
    • Texas Health Steps (THSteps) Toolkit
    • Value-Added Services for STAR, CHIP and STAR Kids
    • Medicaid Provider Information on COVID-19 Coverage
  • Clinical Resources
    • Clinical Resources
    • Behavioral Health
    • Clinical Practice Forms
    • Early Childhood Intervention
    • Medical Policies
    • Vision
    • eviCore Prior Authorization Program
    • Quality Improvements (QI) Toolkits and Tip Sheets
  • Pharmacy
    • Pharmacy
    • Home Delivery Pharmacy (Mail-Order Pharmacy)
    • Benefits and Claims
    • Pharmacy Clinical Edits
    • Preferred Drug List
    • Medicaid (STAR) and CHIP Prior Authorization Forms
    • STAR Kids Prior Authorization Forms