RSV Authorization Forms

Managed Care (Medicaid and CHIP)

Traditional Medicaid

Complete both forms.  Refer to form for requirements and submission instructions. Failure to submit both forms will result in authorization denial. Submit to the Texas Prior Authorization Call Center.

Form Name Form Number
Standard Prior Authorization Request (PDF) TDI NOFR002

Synagis Standard PA Addendum

HHS 1321

CSHCN Services Program

Refer to the list of CSHCN Prior Authorization Requests (forms) in the Pharmacy Provider Procedure Manual.