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Forms and Checklists

Prior Authorization Forms and Checklists

Texas Authorization Referral Form

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

Behavioral Health Inpatient Admission Notification Form

Behavioral Health Inpatient Extended Stay Form

Behavioral Health Discharge Summary Form

Psychological Testing Prior Authorization Request Form

Noninvasive Prenatal Screening (NIPS) Attestation for OBGYN’s Form

OB Attestation for Cystic Fibrosis Screening Form

Therapy Referral Review by Ordering Physician Attestation Form

Navitus’ Prior Authorization Forms

Navitus’ Clinical Edit Forms

Envolve Forms

DHP Provider Services
Ph: 1-877-324-3627 toll-free

DHP Member Services
Ph: 1-877-324-7543 toll-free

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Is your child 18 years old or younger?

* Children up to age 20 can qualify for Medicaid in some cases





Continue

Is your child a US Citizen or legal
permanent resident?





Continue

Does your child live in Texas?





Continue

What is the size of your family?





Continue

Do you fall within the maximum
Monthly / Yearly income range?


Family Size Max Monthly Income Max Yearly Income
1 ≤ $1,346 ≤ $16,147
2 ≤ $1,825 ≤ $21,892
3 ≤ $2,304 ≤ $27,638
4 ≤ $2,782 ≤ $33,383
5 ≤ $3,261 ≤ $39,129
6 ≤ $3,740 ≤ $44,875
7 ≤ $4,219 ≤ $50,620
8 ≤ $4,698 ≤ $56,366

*Income is money you get paid before taxes are taken out.
**A family of one might be a child who does not live with a parent or other relative.





Continue

It appears you may qualify for
STAR or CHIP

Apply for STAR or CHIP through one of the following options:

Call 1-877-543-7669 (1-877-KIDS-NOW)

Call 1-877-DCHP-KIDS for help.

chipmedicaid.org



Apply Now

App on App Store App on Google Play



You are eligible to apply if you:
  • Are an adult who lives more than half time with an uninsured child
  • Are 19 or younger and live on your own
  • Are pregnant (any age)
Paperwork you will need to complete the application:
  • Proof of income (check stub or other income data)
  • Proof of you and your child's Social Security Number
  • Proof of you and your child's residency status or immigration status
'

It appears you may not qualify for
STAR or CHIP

Please visit CHIP/Medicaid for more information:

STAR / CHIP / Medicaid
  1. 1
  2. 2
  3. 3
  4. 4
  5. 5

Is your child 18 years old or younger?

* Children up to age 20 can qualify for Medicaid in some cases





Continue

Is your child a US Citizen or legal
permanent resident?





Continue

Does your child live in Texas?





Continue

What is the size of your family?





Continue

Do you fall within the maximum
Monthly / Yearly income range?


Family Size Max Monthly Income
1 ≤ $1,428
2 ≤ $1,931
3 ≤ $2,434
4 ≤ $2,938
5 ≤ $3,441
6 ≤ $3,944
7 ≤ $4,447
8 ≤ $4,950

For each additional person, add: $504
*Income is money you get paid before taxes are taken out.
**A family of one might be a child who does not live with a parent or other relative.





Continue

It appears you may qualify for
STAR/Medicaid

Apply for STAR/Medicaid through one of the following options:

Call 1-877-543-7669 (1-877-KIDS-NOW)

Call 1-877-DCHP-KIDS for help.

chipmedicaid.org



Apply Now

App on App Store App on Google Play



You are eligible to apply if you:
  • Are an adult who lives more than half time with an uninsured child
  • Are 19 or younger and live on your own
  • Are pregnant (any age)
Paperwork you will need to complete the application:
  • Proof of income (check stub or other income data)
  • Proof of you and your child's Social Security Number
  • Proof of you and your child's residency status or immigration status

It appears you may not qualify for
STAR/Medicaid

Please visit STAR / Medicaid for more information:

STAR / Medicaid
  1. 1
  2. 2
  3. 3
  4. 4
  5. 5

Is your child 18 years old or younger?

* Children up to age 20 can qualify for Medicaid in some cases





Continue

Is your child a US Citizen or legal
permanent resident?





Continue

Does your child live in Texas?





Continue

What is the size of your family?





Continue

Do you fall within the maximum
Monthly / Yearly income range?


Family Size Max Monthly Income
1 ≤ $2,158
2 ≤ $2,918
3 ≤ $3,679
4 ≤ $4,439
5 ≤ $5,200
6 ≤ $5,960
7 ≤ $6,721

For each additional person, add: $761
*Income is money you get paid before taxes are taken out.
**A family of one might be a child who does not live with a parent or other relative.





Continue

It appears you may qualify for
CHIP

Apply for STAR/Medicaid through one of the following options:

Call 1-877-543-7669 (1-877-KIDS-NOW)

Call 1-877-DCHP-KIDS for help.

chipmedicaid.org



Apply Now

App on App Store App on Google Play



You are eligible to apply if you:
  • Are an adult who lives more than half time with an uninsured child
  • Are 19 or younger and live on your own
  • Are pregnant (any age)
Paperwork you will need to complete the application:
  • Proof of income (check stub or other income data)
  • Proof of you and your child's Social Security Number
  • Proof of you and your child's residency status or immigration status

It appears you may not qualify for
CHIP

Please visit CHIP/Medicaid for more information:

CHIP / Medicaid
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