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Provider Forms

 

You'll find all forms we currently use in the following list. Check back frequently to see what's changed.


General Provider Forms

Appeal Request Form (Editable) (PDF 47.96 KB)

Attendant Compensation Rate Enhancement Request Form (PDF 62.2 KB) - The application deadline for the rate enhancement is December 1, 2017 at 5:00 p.m.  Form updated 11.08.2017

Claim Reconsideration Form (PDF 55.64 KB)

Complaint Form (PDF 463.15 KB) - Posted 10.24.2017

Disclosure and Consent Form (Authorization for Release and Use of Confidential Information) (PDF 99.65 KB)

Disclosure and Consent Form (Authorization for Release and Use of Confidential Information) - Español (PDF 110 KB)

Disclosure and Consent Form (Authorization for Release and Use of Health Information) (PDF 98.04 KB)

Disclosure and Consent Form (Authorization for Release and Use of Health Information) - Español (PDF 35.24 KB)

Do Not Resuscitate Order (PDF 27.46 KB)

Employment Assistance Monthly Progress Report (PDF 291.04 KB) - 8.12.2015

Employment Services Initial Assessment (PDF 117.37 KB) - 8.12.2015

JOIN for ME Physician Referral Form (PDF 136.06 KB)

Living Will (PDF 65.26 KB)

LTSS Credentialing Application (PDF 128.41 KB) - 7.28.2016 

LTSS Services Offered Pre-Credentialing Form (PDF 60.2 KB) - 7.28.2016

Medical Power of Attorney (Advanced Directives Act) (PDF 62.83 KB)

Obstetrical Health Risk Assessment Form (PDF 80.21 KB)

Provider Acknowledgment of Receipt of Manaul (PDF 19.51 KB)

Provider Address and Tax Updates - Updated May 12, 2015

Reporting Critical Incidents Including Abuse, Neglect and Exploitation (PDF 512.22 KB) - 10.6.2016

Request for Taxpayer Identification Number and Certification Form (PDF 256.43 KB)

Sleep Study Worksheet (PDF 192.95 KB)

STAR Kids Letter of Intent (PDF 17.1 KB) - 7.28.2016

Supported Employment Monthly Progress Report (PDF 116.37 KB) - 8.12.2015

Texas Department of State Health Services Standard Out-of-Hospital Do-Not-Resuscitate Order (PDF 24.69 KB)

Texas Health Steps Medical Checkup Child Health Records By Age: Helping Make Component Documentation Easier - 3.20.2017