Forms and Checklists - Driscoll Health Plan

Updates to Authorization Letters and Approvals

Please choose from the Forms and Checklists below

Authorization Process for CPW Case Management Services

Behavioral Health Inpatient Extended Stay Form

Behavioral Health Inpatient Admission Notification Form

Behavioral Health Discharge Summary Form

Bilateral Tubal Ligation with Salpingectomy or Oophorectomy Attestation

Change of Provider Letter

CHIP Appeal Request Form

CHIP Appeal Request Form - Spanish

Cystic Fibrosis Carrier Screening Attestation for OB GYNs

DHP STAR/STAR Kids Appeals Adverse Benefit Decision Flyer

DHP STAR/STAR Kids Appeals Adverse Benefit Decision Flyer - Spanish

DHP STAR/STAR Kids Appeal Request Form

DHP STAR/STAR Kids Appeal Request Form - Spanish

DHP STAR/STAR Kids State Fair Hearing and External Medical Review Flyer

DHP STAR/STAR Kids State Fair Hearing and External Medical Review Flyer - Spanish

DHP STAR/STAR Kids State Fair Hearing and External Medical Review Request Form

DHP STAR/STAR Kids State Fair Hearing and External Medical Review Request Form - Spanish

DHP CCP Prior Authorization Request Form

DHP CCP Prior Authorization Request Form Instructions

DHP PCS Practitioner Statement of Need (PSON)

Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form

Initial Prior Auth Request for CPW Case Management Services

Inpatient Clinical Review Request Form

Navitus' Prior Authorization Forms

Navitus' Clinical Edit Forms

Non-Emergency Ambulance Prior Authorization Request

Outpatient Clinical Request Form

Peer-to-Peer Conversation Availability Notification

Prior Auth Request for Additional Visits for CPW Case Management Services

Provider Forms (envolvevision.com)

Psychological Testing Prior Authorization Request Form

Referral Submission Invalid or Unrecognized Procedure Code

Texas Standard Prior Authorization Request Form

Therapy Request Checklist