Application for Texas Identification Number (PDF) | HHS Form 4109 |
Biosynthetic Growth Hormone Agents Prior Authorization Request - CSHCN Services Program | HHS Form 1327 |
CHIP Drug Rebate Agreement | HHS Form 1337 |
Comprehensive Care Program (CCP) Prior Authorization Request Form (PDF) | TMHP Form F00012 |
CSHCN Services Program Rebate Agreement | HHS Form 1343 |
Cystic Fibrosis Treatment Agents (Kalydeco/Orkambi/Symdeko) Prior Authorization Request (Medicaid) | HHS& Form 1338 |
Cystic Fibrosis Treatment Products Authorization Request - CSHCN Services Program | HHS Form 1143 |
Direct Deposit Authorization (PDF) | CPA 74-176 |
Draft Policy Comment Submission | HHS Form 1342 |
Drug Shortage Notification and Expedited Formulary or Preferred Drug List Request | HHS Form 1315 |
Drug Utilization Review (DUR) Board Annual Disclosure | HHS Form 1349 |
Drug Utilization Review (DUR) Board Public Testimony Registration | HHS Form 1320 |
Drug Utilization Review (DUR) Board Written Testimony Registration | HHS Form 1334 |
Emflaza Prior Authorization Request | HHS Form 1347 |
Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form (PDF) | TMHP Form F00030 |
HHS Data Use Agreement (PDF) | |
HHS Uniform Terms and Conditions (PDF) | |
Increlex Authorization Request - Medicaid | HHS Form 1357 |
KHC Program Drug Rebate Agreement | HHS Form 1329 |
Long-acting Reversible Contraception (LARC) Product Forms | |
MCO Search Update Request | HHS Form 1344 |
Medicaid Fee-For-Service Prior Authorization Reconsideration Request | HHS Form 1322 |
OxyContin Authorization Request - Medicaid | HHS Form 1353 |
Palivizumab (Synagis) Prior Authorization Request - Medicaid | HHS Form 1321 |
Palivizumab (Synagis) Prior Authorization Request - CSHCN Services Program | HHS Form 1325 |
PCSK9 Inhibitor Agents Authorization Request - Medicaid | HHS Form 1355 |
Pharmacy Claims Billing Request | HHS Form 1319 |
Pharmacy Ownership Transfer Affidavit | HHS Form 1332 |
Phosphate Binder Agents Authorization Request - Medicaid | HHS Form 1348 |
Prior Quarter Adjustment Statement | CMS 304a |
Reconciliation of State Invoice | CMS 304 |
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits (PDF) - Medicaid | TDI Form NOFR002 |
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits (PDF) - CSHCN Services Program | TDI Form NOFR002 |
Value-Based Agreement Concept | HHS Form 1402 |
Xyrem Authorization Request - Medicaid | HHS Form 1356 |