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Authorization request form

Texas authorization form 2025

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The document is the Texas Standard Prior Authorization Request Form for Health Care Services, mandated by the Texas Department of Insurance. It outlines the process for requesting prior authorization from health benefit plan issuers, including Medicaid and CHIP, effective September 1, 2015. The form must be sent to the issuer and not to state agencies or employers. It specifies what the form should be used for, details on urgent reviews, and requirements for clinical documentation. Additionally, it provides sections for patient and provider information, service requests, and necessary codes.

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Click ‘Get Form’ to open the Texas Standard Prior Authorization Request Form in the editor.
In Section I, enter the Issuer Name, Phone, and Fax details. Ensure that all information is accurate for proper processing.
Move to Section II and select the Review Type (Non-Urgent or Urgent) and Request Type (Initial Request or Extension/Renewal/Amendment). This helps prioritize your request.
Fill out Section III with Patient Information including Name, DOB, Member ID, and any relevant clinical reasons for urgency.
In Section IV, provide details about the Requesting Provider or Facility. If applicable, indicate if they are also the Service Provider by entering 'Same'.
Detail the Services Requested in Section V. Include CPT codes and diagnosis descriptions as required. Attach any necessary documentation in Section VI.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (284 Votes)
2015	4.9 Satisfied (36 Votes)

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