Texas Health and Human Services Forms

This form is used for requesting authorization for growth hormone products for children with special healthcare needs in the state of Texas.

This form is used for filing a long-term care claim in the state of Texas. It is used to request reimbursement for expenses related to long-term care services.

This Form is used for accessing the Pharmacy Eligibility Verification Portal in Texas.

This form is used for pharmacies in Texas to establish an agreement for electronic remittance advice with insurance companies or third-party payers.

This Form is used for verifying civil services benefits in Texas.

This Form is used for requesting information from the U.S. Department of Veterans Affairs and for giving authorization by individuals in Texas.

This Form is used for certifying information related to the Texas Drug Code Index. It is specifically used for Form 1326 in Texas for Drug Code Index Certification of Information (COI).

This document is used for the Kidney Health Care Program Drug Rebate Agreement in Texas.

This form is used for adding a prior authorization addendum for the Medicaid program in Texas specifically for Xenical medication.

This form is used for Medicaid beneficiaries in Texas who need prior authorization for the prescription medication Xenical at a clinic.

This form is used for submitting a retroactive claim for Medicaid in the state of Texas.

This form is used for enrolling a pharmacy in Texas. It is an agreement that outlines the terms and conditions for pharmacies to participate in certain programs or networks.

This Form is used for requesting updates to managed care resources in the state of Texas.

This form is used for requesting a refill authorization for antiviral agents for hepatitis C virus under the Medicaid program in Texas.

This Form is used for adding a fee for service Medicaid addendum to the Makena Standard Pa program in Texas.

This Form is used for requesting authorization for Makena medication under Fee for Service Medicaid in Texas.

This form is used for adding a standard PA addendum for Medicaid claims of phosphate binders in Texas.

This form is used for requesting to withdraw from the class application process in Texas.

This is a Texas-specific form used to add Oxycontin to the standard preferred drug list for Medicaid patients. It is an addendum to Form 1353 for Medicaid purposes.

This form is used for cancelling a Class S Request in Texas.

This form is used for requesting authorization for Pcsk9 inhibitors under Medicaid Fee-For-Service in Texas.

This Form is used for adding the Medicaid Fee-For-Service standard for Pcsk9 Inhibitors in Texas.

This form is used for adding Medicaid coverage for Increlex Standard Pa in Texas.

This document is for Physician Assistants in Texas who want to participate in the Medicaid Electronic Health Record (EHR) Incentive - Promoting Interoperability (PI) Program. It is a form used to attest their eligibility for certain incentives and benefits.

This Form is used for certifying debarment, suspension, ineligibility, and voluntary exclusion for covered contracts in Texas. It ensures that individuals or entities are eligible to participate in government contracts.

This form is used for federal lobbying certification in the state of Texas. It is required for individuals or organizations engaged in lobbying activities at the federal level in Texas to disclose certain information.

This Form is used for implementing value-based agreements in the healthcare industry in Texas. It outlines the terms and conditions for providers and payers to collaborate in delivering healthcare services based on the value and outcomes achieved.

This document is used for requesting a medical need assessment or verification of Rug-III category in Texas.