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Provider Forms



Download our Provider Forms Below

Claim Forms

  • Corrected Claim Form
  • Clean Claim Elements
  • CMS 1500 Claim Form Instruction 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
  • Secondary Locations for Organization
  • Credentialing & Re-Credentialing Checklist for Physician
  • Texas Standardized Credentialing Application

Health Services Forms

    • Therapy Request Checklist
    • Listing of Services Requiring Prior Authorization
    • 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
  • Specialist as a PCP Request Form

Misc. Forms

  • EFT Form
  • El Paso Health Payer Identifications
  • Electronic Remittance Advice (835) Request Form
  • HealthX Fax System
Provider Manual
Provider Manual→
DownloadProvider Directories &
Member Handbooks →
SearchPrior
Authorizations →
El Paso Health Newsletter
HHSC Notifications →
Texas Health StepsTexas Health Steps
Resources for Providers →
El Paso Health Newsletter
Provider Newsletter →
Our Case Management Program
Our Case Management Program→
Clinical Practice Guidelines
Clinical Practice Guidelines→
Clinical Practice Guidelines
Provider Resources→

Career Opportunities

For current job openings at El Paso Health; please visit the University Medical Center of El Paso Jobs website.


El Paso Health


1145 Westmoreland Drive
El Paso, TX 79925-5615

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P.O. Box 971370
El Paso, TX 79997-1370

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P.O. Box 971100
El Paso, TX 79997-1100

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