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The following documents are available in Adobe PDF format.

Adobe Acrobat Reader is require to view the PDF documents. If you do not have Acrobat Reader, it is available free for Mac & PC at Adobe's website. Simply select the correct version for your particular computer and follow the directions provided. PDF files retain all document formatting, insuring the copy you get when you print the file will be the same as the one you would get from our office.
 
CHIP Perinate Provider Manual
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CHIP Perinate Provider Manual
Exhibit 01 - Request for Continuity/Transition of Care
Exhibit 02 - Authorization List
Exhibit 03 - Office Assessment Tool
Exhibit 04 - Medical Records Documentation Guidelines
Exhibit 05 - Preventive Care Recommendations
Exhibit 06 - Texas Referral Authorization Form
Exhibit 07 - Provider Complaint Form
Exhibit 08 - Provider Appeal Form
Exhibit 09 - CMS HCFA 1500 (form)
Exhibit 09A - CMS HCFA 1500 (back)
Exhibit 10 - UB-92
Exhibit 11 - Explanation of Payment Form
Exhibit 12 - Member Education and Request Form
Exhibit 13 - Children with Complex Special Health Care Needs Form
Exhibit 14 - PCP Request for Member Transfer
Exhibit 15 - Texas Vaccine for Children Forms
Exhibit 16 - Behavioral Health Authorization Request
Exhibit 17 - Claims Appeal Submission Form
Exhibit 18 - Psychological Testing Form
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Exhibit 19 - Cost Sharing Schedule
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