PDF
Word
This version of the form is not currently in use and is provided for reference only. Download this version of
Form 1325
for the current year.
Form 1325 Synagis Authorization Request (Cshcn) - Texas
What Is Form 1055?
This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form 1055?
A: Form 1055 is the Texas Vendor Drug Program Synagis Authorization Request (Cshcn) form.
Q: What is the purpose of Form 1055?
A: Form 1055 is used to request authorization for the medication Synagis through the Texas Vendor Drug Program for children with special health care needs (CSHCN).
Q: What is Synagis?
A: Synagis is a medication used to prevent a serious respiratory infection called respiratory syncytial virus (RSV) in high-risk infants.
Q: Who is eligible for the Texas Vendor Drug Program?
A: Children with special health care needs (CSHCN) are eligible for the Texas Vendor Drug Program.
Q: What information is needed to complete Form 1055?
A: The form requires information about the patient, healthcare provider, and medical necessity for Synagis.
Form Details:
- Released on August 1, 2019;
- The latest edition provided by the Texas Health and Human Services;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form 1055 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.
Download Form 1325 Synagis Authorization Request (Cshcn) - Texas
1
2
3
4
