Corrected Claim Form
Clean Claim Elements
CMS 1500 02-12 Claim Form Manual
New CMS 1500 Guidance

Request for a Review by an Independent Review Organization – English
Request for a Review by an Independent Review Organization – Spanish

Fiscal Year 2025 Enhancement for Attendant Compensation- Request for Participation
DME Supplies Form
Demographic Form
W9 Form – Request for Taxpayer Identification Number and Certification
Credentialing Checklist for Organization/Facility
Credentialing Application for Organization
Secondary Locations for Organization
Credentialing & Re-Credentialing Checklist for Physician
Texas Standardized Credentialing Application

ABA Request Checklist
Therapy Request Checklist
CCP Prior Authorization Request Form
STAR/CHIP Pre-Authorization Flyer EFF 10.1.2023
Texas Standard Prior Authorization Form for Health Care Services
Prior Authorization Form – Out of Area Inpatient
Prior Authorization Form – NICU
IUD Abandoned Unit Return Form
Case Management Referral Form
Therapy Request Checklist
Behavioral Health Prior Authorization Form

Authorization to Disclose information to PCP
1027 Medicaid Eligibility Form
Specialist as a PCP Request Form
Primary Care Provider Change Request Form

El Paso Health Payer Identifications
Electronic Remittance Advice (835) Request Form
HealthX Fax System