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Access and Availability Standards

Authorization List

Behavioral Health Authorization Request for Additional Visits

Care Plan for Children with Complex Special Health Care Needs Form

CHIP Cost Sharing Schedule

Claim Appeal Submission Form

CMS - 1500 Claim Form

Community First CHIP Member ID Card

Explanation of Payment (EOP)

Member Education Request Form

Member/Client Acknowledgement Statement

Pediatric Preventive Care Recommendations: Exhibit 9A - AAP Recommendations for Preventive Pediatric Health Care Exhibit 11B - Recommended Immunization Schedule 0-6 Years of Age Exhibit 11C - Recommended Immunization Schedule 7-18 Years of Age Exhibit 11D - Catch-Up Immunization Schedule 4 Months - 18 Years

Exhibit 8A - PCP: 14.1 PCP Documentation Guidelines 2011 14.2 PCP Medical Record Review Tool 2011

Exhibit 8B - OB/Gyn: 18.4 OB-GYN Documentation Guidelines 2011 18.5 OB-GYN Medical Record Review Tool 2011

Exhibit 8C - Behavior Health: 07.1 Behavioral Health Documentation Guidelines 2011 07.2 Behavioral Health Medical Record Review Tool 2011

Exhibit 8D - Specialist: 14.3 Specialist Documentation Guidelines 2011 14.4 Specialist Medical Record Review Tool 2011

Private Pay Agreement

Provider Appeal Form

Provider Complaint Form

Provider Request for Transfer

Quick Reference Guide

Request for Continuity Transition of Care Form

Suspicious Activity Report (Member)

Suspicious Activity Report (Provider)

TB Report of Case and Patient Services

Texas Referral/Authorization Form

Texas Vaccine for Children Form

UB-04 Claim Form