CHIP Provider Manual

Community First CHIP Provider Manual

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