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
DHP Provider Services
Ph: 1-877-324-3627 toll-free
DHP Member Services
Ph: 1-877-324-7543 toll-free