Forms

Most HHSC forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system. Refer to the instructions for accessing these types of forms.

Form Name	Form Number
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) Instructions (PDF)	TMHP Form F00012
CSHCN Services Program Rebate Agreement	HHS Form 1343
Cystic Fibrosis Treatment Agents 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
Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form (PDF) Instructions (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 Bayer Abandoned Unit Frequently Asked Questions (FAQ) and Return Form (PDF) Cooper Surgical Abandoned Unit Process (PDF) Organon Abandoned Unit Program FAQ (PDF) Organon Abandoned Unit Return Form (PDF)
Managed Care Resources Update Request	HHS Form 1344
Medicaid Fee-For-Service Prior Authorization Reconsideration Request	HHS Form 1322
OxyContin Authorization Request - Medicaid	HHS Form 1353
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
Synagis Prior Authorization Prior Authorization Request - Medicaid	HHS Form 1321
Synagis Prior Authorization Prior Authorization Request - CSHCN Services Program	HHS Form 1325
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