Outpatient request form: Fill out & sign online

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01. Edit your outpatient request form online

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02. Sign it in a few clicks

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03. Share your form with others

Send outpatient request health via email, link, or fax. You can also download it, export it or print it out.

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Click ‘Get Form’ to open the outpatient request form in the editor.
Begin by filling out the 'Requesting Provider Information' section. Include the provider's name, telephone number, fax number, and state license number.
Next, indicate the 'Service Type' by selecting from options such as Physical Therapy, Occupational Therapy, or Outpatient Surgery.
Complete the 'Patient Information' section. Ensure you provide the patient's full name, date of birth, address, and contact information.
In the 'Requested Service Information' area, detail the diagnosis and description of services required. Include CPT/HCPC/NDC codes where applicable.
If necessary, attach any clinical history or supporting documents directly through our platform for a seamless submission process.

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What is the fax number for Texas Standard prior authorization form?

Return the form by To send this back to us, you can either: (a) give it to the employee listed above, (b) mail it in the pre-paid envelope, or (c) fax it to 1-877-447-2839.

What is the fax number for Texas HHSC?

Providers can fax the Pharmacy Prior Authorization form to CVS Health at 1-888-836-0730 or call the CVS Utilization Management Department at (877) 433-7643. We encourage enrollees to use the CVS Caremark Mail Order Pharmacy. Below you will find the CVS Caremark Mail Order Fax Form.

What is the fax number for the Texas Standard prior authorization Form?

Complete / Review information, sign, and date. Fax signed forms to Molina Pharmacy Prior Authorization Department at 1-888-487-9251. Please contact Molina Pharmacy Prior Authorization Department at 1-855-322-4080 with questions regarding the prior authorization process.

Does Texas Medicaid require prior authorization?

Except for emergency services, post-stabilization services, and services provided to you during an approved inpatient admission, all services from an out-of-network provider must be prior authorized. Claims for services from out-of-network providers that are not approved before the service is given may be denied.

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