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Provider Manual

The following documents are provided in Adobe PDF format.
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Provider Manual (November 2013) (without exhibits)
Exhibit 01 - Request for Continuity - Transition of Care
Exhibit 02 - Authorization List
Exhibit 03 - Provider Office Assessment Tool
Exhibit 04 - Physician Medical Records Audit Tool
Exhibit 05 - Pediatric Preventive Care Recommendations
Exhibit 06 - Texas Referral Authorization Form
Exhibit 07 - Provider Complaint Form
Exhibit 08 - Provider Appeal Form
Exhibit 09 - TB Report of Case and Patient Services
Exhibit 10 - TB Report Follow-Up
Exhibit 11 - TB Case Report
Exhibit 12 - Member Education Request Form
Exhibit 13 - Children with Complex Special Health Care Needs Form
Exhibit 14 - Provider Request for Transfer
Exhibit 15 - Texas Vaccine for Children Forms
Exhibit 16 - Behavioral Health Authorization Request
Exhibit 17 - Psychological Testing Request Form
Exhibit 18 - Behavioral Health Report to PCP
Exhibit 19 - Appeal Submission Form
Exhibit 20 - Emergency Medical Services Certification - Form 3038
Exhibit 21 - CMSHCFA-1500
Exhibit 22 - UB-04
Exhibit 23 - Explanation of Payment (EOP)
Exhibit 24 - CHIP Perinatal Sample Member ID Card (MOM)
Exhibit 25 - CHIP Perinatal Sample Member ID Card (Newborn)
Exhibit 26 - Report of Pregnancy
Exhibit 27 - Private Pay Agreement
Exhibit 28 - Member-Client Acknowledgement Statement
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Community First Health Plans is an affiliate of the University Health System.