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ALERT! We now encourage our patients to save their spot in line before coming into the clinic.

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Welcome to your new website: This new website will make it easier for you to take care of what you need to do in just a few clicks: Learn more

Members: Remember to take the annual CAHPS Survey! Learn more

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Provider Forms and Manuals

Below you will find useful forms for you and your practice. If you wish to open the following forms, you must have Adobe Acrobat Reader installed on your computer. To download a form, right click on one of the links below and select "Save Target As."

To download a free copy of Adobe Acrobat Reader, click here.

Reimbursement Information for CHIP Co-Payment Waiver

Authorizations

  • Standard Prior Authorization Form
  • Medical Services Fax Line - 832-825-8760 or Toll-Free 1-844-473-6860
  • Behavioral Health Services Fax Line - 832-825-8767 or Toll-Free 1-844-291-7505
  • LTSS and Private duty Nursing Fax Line - 346-232-4757 or Toll-Free 1-844-248-1567

Case Management

Physician Requests

Other Forms