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EXHIBIT 1: Request for Continuity/Transition of Care
EXHIBIT 10: Psychological Testing Request Form
EXHIBIT 11: Member Education Request Form
EXHIBIT 12: Medical Record Review Tool
EXHIBIT 13: Member/Client Acknowledgement Statement
EXHIBIT 15: Consent to Use Physician Assistant/Nurse Practitioner
EXHIBIT 16: CMS-1500 Blank Paper Claim Form and Instructions
EXHIBIT 17: UB 04 Claim Form and Instructions
EXHIBIT 18: Private Pay Agreement
EXHIBIT 19: Explanation of Payment – Sample
EXHIBIT 2: Your Texas Benefits Medicaid Care
EXHIBIT 20: Provider Complaint Form
EXHIBIT 21: Claims Appeal Submission Form
EXHIBIT 22: Medicaid Eligibility Verification Form (H 1027-A)
EXHIBIT 23: Current Immunization Schedule for Pediatrics
EXHIBIT 24: Blood Lead Screening and Testing Guidelines
EXHIBIT 25: Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form
EXHIBIT 26: Community First Provider Billing Guidelines
EXHIBIT 27: Form H3038, Emergency Medical Services Certification
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