Provider Forms and Manuals

Below you will find useful forms for you and your practice. If you wish to open the following forms, you must have Adobe Acrobat Reader installed on your computer. To download a form, right click on one of the links below and select "Save Target As."

To download a free copy of Adobe Acrobat Reader, click here.

Reimbursement Information for CHIP Co-Payment Waiver

• Reimbursement request for waived CHIP co-payments

Authorizations

• Standard Prior Authorization Form
• Medical Services Fax Line - 832-825-8760 or Toll-Free 1-844-473-6860
• Behavioral Health Services Fax Line - 832-825-8767 or Toll-Free 1-844-291-7505
• LTSS and Private duty Nursing Fax Line - 346-232-4757 or Toll-Free 1-844-248-1567

Case Management

• Asthma Action Plan
• Member Referral for Case Management
• Targeted Behavioral Health Case Management and Rehabilitative Services Request Form

Physician Requests

• Physician Request for Member Education
• Physician Request for Removal of Member From Panel 
• Primary Care by Specialist Request Form
• Specialist Scheduling Assistance Form

Other Forms

• Claim Appeal/Resubmission Form
• Medicaid Electronic Visit Verification (EVV) Small Alternative Device Agreement
• Provider Electronic Visit Verification Vendor System Selection
• Provider Information Form
• Provider Information Change Form