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Access and Availability Standards

Authorization List

Behavioral Health Authorization Request for Additional Visits

Behavioral Health Report to PCP

Care Plan for Children with Complex Special Health Care Needs Form

Claim Appeal Submission Form

CMS - 1500 Claim Form

Community First CHIP Perinatal Sample Member ID Card (Mom)

Community First CHIP Perinatal Sample Member ID Card (Newborn)

Emergency Medical Services Certification - Form 3038

Explanation of Payment (EOP)

Member Education Request Form

Member/Client Acknowledgement Statement

Pediatric Preventive Care Recommendations

Physician Medical Record Audit Tool

Private Pay Agreement

Provider Appeal Form

Provider Complaint Form

Provider Request for Transfer

Psychological Test Request to PCP

Quick Reference Guide

Report of Pregnancy

Request for Continuity/Transition of Care

Suspicious Activity Report (Member)

Suspicious Activity Report (Provider)

TB Case Report

TB Report Follow-Up

TB Report of Case and Patient Services

Texas Referral/Authorization Form

Texas Vaccine for Children Form

UB-04 Claim Form