Forms
To locate a specific form, type the title or a keyword in the Title field below. Use the Programs, Topics, and Categories drop down options to further narrow your results.
Authorization
Authorization/Prior Authorization
- CSHCN Services Program Authorization and Prior Authorization Request for Cardiorespiratory Monitor (CRM) Form and Instructions (156.37 KB)
- CSHCN Services Program Authorization and Prior Authorization Request for Durable Medical Equipment (DME) Form and Instructions (316.6 KB)
- CSHCN Services Program Authorization and Prior Authorization Request for Hemophilia Blood Factor Products Form and Instructions (99.53 KB)
- CSHCN Services Program Request for Authorization and Prior Authorization Request Form and Instructions (102.98 KB)
Certification Documentation
- CSHCN Services Program Home Health Skilled Nursing Request and Plan of Care Form and Instructions (244.96 KB)
- CSHCN Services Program Wheelchair Seating Evaluation Form (403.86 KB)
- Documentation of Receipt (English) (62.2 KB)
- Documentation of Receipt (Spanish) (56.36 KB)
- Reimbursement Request for Transportation of the Remains of Deceased Clients (41.29 KB)
- Texas Medicaid and CSHCN Services Program Handicapping Labio-Lingual Deviation (HLD) Index Score Sheet (55.74 KB)
- Vision Care Eyeglass Client Certification Form (50.29 KB)
- Vision Care Eyeglass Client Certification Form (Spanish) (52.74 KB)
Legal
- Abortion Certification Statements Form (16.75 KB)
- Authorization to Release Confidential Information (73.64 KB)
- Authorization to Release Confidential Information (Spanish) (138.24 KB)
- Business Records Affidavit (68.32 KB)
- Child Abuse Reporting Guidelines (18 KB)
- Child Abuse Reporting Guidelines--Checklist for HHSC Monitoring (16.96 KB)
- Children with Special Health Care Needs (CSHCN) Services Program Client Application (English) (1.37 MB)
- Children with Special Health Care Needs (CSHCN) Services Program Client Application (Spanish) (816.35 KB)
- CSHCN IPPA Certification Form (63.75 KB)
- Form to Release CSHCN Services Program Claims History (English) (43.26 KB)
- Form to Release CSHCN Services Program Claims History (Spanish) (43.26 KB)
- Medical Records Declaration (136.14 KB)
- Tort Response Form (66.32 KB)
Miscellaneous
- CSHCN Drug Copay Form (92.29 KB)
Prior Authorization
- CSHCN Services Program Criteria for Dental Therapy Under General Anesthesia (95.54 KB)
- CSHCN Services Program Genetic Testing for Hereditary Breast and/or Ovarian Cancer Prior Authorization Form (161.39 KB)
- CSHCN Services Program Home Telemonitoring Services Prior Authorization Request (96.71 KB)
- CSHCN Services Program Prescribed Pediatric Extended Care (PPECC) Services Prior Authorization Request Form and Instructions (374.79 KB)
- CSHCN Services Program Prior Authorization Request for Augmentative Communication Devices (132.5 KB)
- CSHCN Services Program Prior Authorization Request for CPAP or RAD (356.84 KB)
- CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services (189.98 KB)
- CSHCN Services Program Prior Authorization Request for Diabetic Equipment and Supplies Form (193.7 KB)
- CSHCN Services Program Prior Authorization Request for Diapers, Pull-ups, Briefs, or Liners Form and Instructions (215.36 KB)
- CSHCN Services Program Prior Authorization Request for Extension of Outpatient Therapy (TP2) Form and Instructions (250.08 KB)
- CSHCN Services Program Prior Authorization Request for Hospice Services (151.96 KB)
- CSHCN Services Program Prior Authorization Request for Initial Outpatient Therapy (TP1) Form and Instructions (195.5 KB)
- CSHCN Services Program Prior Authorization Request for Inpatient Hospital Admission—For Use by Facilities Only Instructions (186.69 KB)
- CSHCN Services Program Prior Authorization Request for Inpatient Psychiatric Care Form and Instructions (162.51 KB)
- CSHCN Services Program Prior Authorization Request for Inpatient Rehabilitation Admission Form and Instructions (269.54 KB)
- CSHCN Services Program Prior Authorization Request for Inpatient Surgery Form and Instructions - For Surgeons Only (171.18 KB)
- CSHCN Services Program Prior Authorization Request for Medical Foods Form and Instructions (138.6 KB)
- CSHCN Services Program Prior Authorization Request for Medical Nutritional Products Form and Instructions (135.59 KB)
- CSHCN Services Program Prior Authorization Request for Outpatient Surgery - For Outpatient Facilities and Surgeons (171.16 KB)
- CSHCN Services Program Prior Authorization Request for Oxygen Therapy Form and Instructions (307.45 KB)
- CSHCN Services Program Prior Authorization Request for Pulse Oximeter Form and Instructions (231.85 KB)
- CSHCN Services Program Prior Authorization Request for Renal Dialysis Treatment (165.33 KB)
- CSHCN Services Program Prior Authorization Request for Respiratory Care CRCP (177.23 KB)
- CSHCN Services Program Prior Authorization Request for Secretion and Mucus Clearance Devices Form and Instructions (259.04 KB)
- CSHCN Services Program Prior Authorization Request for Stem Cell or Renal Transplant (194.12 KB)
- Texas Medicaid and CSHCN Services Program Non-emergency Ambulance Exception Prior Authorization Request (108.86 KB)
- Texas Medicaid and CSHCN Services Program Non-emergency Ambulance Prior Authorization Request (183.25 KB)
Remittance and Claim Status Forms
- Claim Status Inquiry Authorization for Acute Care Providers (287.9 KB)
- CSHCN Services Program Refund Information Form (63.61 KB)
- Electronic Remittance Advice Agreement (289.31 KB)