Provider Forms

Download our Provider Forms Below

• Claims Forms

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

• Complaints and Appeals Forms

  • Fair Hearing Request Form English
  • Fair Hearing Request Form Spanish
  • Request for a Review by an Independent Review Organization
  • Request for a Review by an Independent Review Organization – Spanish

• Credentialing Packet Forms

  • DME Supplies Form
  • Demographic Form
  • W9 Form – Request for Taxpayer Identification Number and Certification
  • Credentialing Checklist for Organization/Facility
  • Credentialing Application for Organization
  • Credentialing & Re-Credentialing Checklist for Physician
  • Texas Standardized Credentialing Application

• Health Services Forms

  • Pre-Authorization Flyer – STAR/CHIP EFF 4.1.2017
  • Texas Standard Prior Authorization Form for Health Care Services
  • Behavioral Health Prior Authorization Form
  • Prior Authorization Form – Out of Area Inpatient
  • Prior Authorization Form – NICU
  • IUD Abandoned Unit Return Form
  • Case Management Referral Form

• Members Services Forms

  • Authorization to Disclose information to PCP
  • 1027 Medicaid Eligibility Form
  • Private Pay Form
  • Specialist as a PCP Request Form

• Misc. Forms

  • EFT Form
  • EDI Provider Instruction Sheet
  • EDI Request Form
  • HealthX Fax System