18886323862 2026

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The document is the Texas Standard Prior Authorization Request Form for Health Care Services, which must be used by health benefit plan issuers to request prior authorization for healthcare services. It outlines submission instructions, eligibility requirements, and details on how to complete the form. The form is applicable to various public and commercial health plans in Texas and includes sections for patient information, provider details, service requests, and clinical documentation. It emphasizes that the form should not be used for appeals or other inquiries unrelated to prior authorization.

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Click ‘Get Form’ to open the Texas Standard Prior Authorization Request Form for Health Care Services in the editor.
Begin with Section 1, Submission. Enter the name of the issuer you are submitting the request to, along with their phone and fax numbers. Make sure to include the date of submission.
In Section 2, General Information, select whether your request is urgent or non-urgent. If urgent, provide a brief clinical reason for urgency.
Proceed to Section 3, Patient Information. Fill in all required fields including patient name, subscriber name (if different), date of birth, and member ID number.
In Section 4, Provider Information, enter details for both the requesting provider and service provider. Ensure that NPI numbers and contact information are accurate.
Section 5 requires you to specify services requested along with relevant codes (CPT, ICD). Provide detailed descriptions and attach any necessary documentation in Section 6.

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