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 NameForm Number
Application for Texas Identification Number (PDF)HHS Form 4109
Biosynthetic Growth Hormone Agents Prior Authorization Request - CSHCN Services ProgramHHS Form 1327
CHIP Drug Rebate AgreementHHS Form 1337

Comprehensive Care Program (CCP) Prior Authorization Request Form (PDF)

TMHP Form F00012
CSHCN Services Program Rebate AgreementHHS Form 1343
Cystic Fibrosis Treatment Agents Authorization Request - MedicaidHHS Form 1338
Cystic Fibrosis Treatment Products Authorization Request - CSHCN Services ProgramHHS Form 1143
Direct Deposit Authorization (PDF)CPA 74-176
Draft Policy Comment SubmissionHHS Form 1342
Drug Shortage Notification and Expedited Formulary or Preferred Drug List RequestHHS Form 1315
Drug Utilization Review (DUR) Board Annual DisclosureHHS Form 1349
Drug Utilization Review (DUR) Board Public Testimony RegistrationHHS Form 1320
Drug Utilization Review (DUR) Board Written Testimony RegistrationHHS Form 1334
Electronic Certificate of Information (ECOI) Portal AccessHHS Form 1403

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 - MedicaidHHS Form 1357
KHC Program Drug Rebate AgreementHHS Form 1329

Long-acting Reversible Contraception (LARC) Product Forms

 
Managed Care Resources Update RequestHHS Form 1344
Manufacturer Contact Form (Magellan Medicaid Administration) 
Medicaid Fee-For-Service Prior Authorization Reconsideration RequestHHS Form 1322
OxyContin Authorization Request - MedicaidHHS Form 1353
PCSK9 Inhibitor Agents Authorization Request - MedicaidHHS Form 1355
Pharmacy Claims Billing RequestHHS Form 1319
Pharmacy Electronic Remittance Advice AgreementHHS Form 1316
Pharmacy Eligibility Verification Portal AccessHHS Form 1317
Pharmacy Ownership Transfer AffidavitHHS Form 1332
Phosphate Binder Agents Authorization Request - MedicaidHHS Form 1348
Prior Quarter Adjustment StatementCMS 304a
Reconciliation of State InvoiceCMS 304
Synagis Prior Authorization Prior Authorization Request - MedicaidHHS Form 1321
Synagis Prior Authorization Prior Authorization Request - CSHCN Services ProgramHHS Form 1325
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits (PDF) - MedicaidTDI Form NOFR002
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits (PDF) - CSHCN Services ProgramTDI Form NOFR002
Value-Based Agreement ConceptHHS Form 1402
Xyrem Authorization Request - MedicaidHHS Form 1356