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Medicaid tp form 2026

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The document provides detailed instructions for completing the CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1) form. It emphasizes the importance of submitting the most recent version of the form, ensuring all sections are completed to avoid claim denials, and includes guidelines for client and provider information, evaluation summaries, service requests, and required signatures. Additionally, it specifies modifiers needed for different therapy services.

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Click ‘Get Form’ to open the Medicaid TP form in the editor.
Begin by filling out the Client Information section. Enter the client's first name, last name, CSHCN Services Program number, date of birth, and address including city and ZIP code.
In the Evaluation Summary section, input the date of evaluation and check the appropriate type of evaluation (PT, OT, or SLP). Remember to attach a copy of the initial evaluation.
For the Service Request section, indicate procedure codes, modifiers (GP for PT, GO for OT), dates of service (not exceeding six months), and frequency per week or month.
Complete the Provider Information section by entering provider details such as name, TPI, NPI, taxonomy code, contact information, and ensure that the provider signs and dates the form.

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Versions	Form popularity	Fillable & printable
2014	4.9 Satisfied (391 Votes)
2007	4.4 Satisfied (397 Votes)

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