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Driscoll prior authorization form 2026

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The Texas Referral/Authorization Form is a document used to request medical referrals and authorizations for patients under various health plans, including CHIP and STAR/Medicaid. It requires detailed patient information, the referring physician's details, and specifics about the requested services. The form emphasizes that completing it does not guarantee payment and advises verification of member eligibility with the health plan. Additionally, it includes sections for health services response, indicating approval or denial of the referral.

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Click ‘Get Form’ to open the driscoll prior authorization form in the editor.
Begin by filling out the health plan name and date at the top of the form. Ensure you select the appropriate health plan type, such as CHIP or STAR/Medicaid.
In the patient info section, enter the patient's full name, date of birth, sex, phone number, member ID, and optional social security number.
Complete the 'Referred By' section with the physician's name and provider number. Indicate whether this is a routine or urgent referral.
Specify the requested start and end dates for services along with the diagnosis code and scope of referral. Include any specific services requested in detail.
Fill in details about the provider being referred to, including their specialty type and contact information.
Finally, provide any necessary comments or clinical history before signing at the bottom of the form.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How to obtain prior authorization?

The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patients insurance provider. As mentioned in the How does prior authorization work? section above, this will then often prompt a time-consuming back and forth between the provider and payer.

Can I submit a prior authorization myself?

The patient or their representative can contact their insurance company and provide the relevant information to start the Prior Authorization process. Its best to confirm with the healthcare provider if they have the information and are willing to submit the request.

Can a doctors office charge for prior authorization?

If you need prior authorization, your doctors office will process the request for you at no charge. They will follow up with your insurance company until the request is approved or denied. This process can involve a great deal of back and forth.

Who handles submitting a request for a prior authorization for care?

Call the TMHP PCS Prior Authorization Inquiry Line at 1-888-648-1517 and ask whether an authorization is in process.

What is the phone number for Tmhp prior authorization?

Prior authorization requires your doctor or provider to obtain approval from your health plan before providing health care services or prescribing prescription drugs. Without prior authorization, your health plan may not pay for your treatment or medication. (Emergency care doesnt need prior authorization.)

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Who deals with prior authorization?

Your health care provider can make the prior authorization request. If your provider submits the request, they will send the required information to your health plan. You may need to fill out forms for your providers office.

Who is responsible for requesting prior authorization?

The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patients insurance provider.

Driscoll prior authorization form 2026

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See more driscoll prior authorization form versions

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Got questions?

How to obtain prior authorization?

Can I submit a prior authorization myself?

Can a doctors office charge for prior authorization?

Who handles submitting a request for a prior authorization for care?

What is the phone number for Tmhp prior authorization?

Security and compliance

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Who deals with prior authorization?

Who is responsible for requesting prior authorization?

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