DSHS Community Health Services Forms

Do you need a to submit a form for your particular service? The forms home page has every form Family and Community Health staff and contractors will need. Just click on the service area you are interested in and the form you need should be listed below.

• Breast and Cervical
• Contractor Vouchers and Reporting
• Epilepsy
• Family Planning
• Quality Management Review Tools and Instructions for FY11
• Primary Health Care
• Title V MCH Fee for Service

Breast and Cervical

• DSHS Funding Source Worksheet – Screening and Eligibility Form
• DSHS Funding Source Worksheet   
• DSHS Funding Source Worksheet – Worksheet Instructions (20 KB, Word)
• BCCS Data Collection Tools & Med-IT User Request Form
• FY10 Contract Renewal Application Packet & Clinical Cost Worksheet
• Case Management Forms
• Medicaid for Breast and Cervical Cancer (MBCC) - formerly Treatment Act
• Other Forms and Reports
  • Monthly Reports - FY07
  • Monthly Reimbursement Requests - FY07
  • Quarterly Reports
  • Annual Demographic Report
  • Notice of Grant Awards
    
• BCCS Data Collection Tools
  
  • BCCS Breast Cancer Diagnostic Form (76 Kb, PDF)
  • BCCS Cervical Cancer Diagnostic Form (72 Kb, PDF)
  • BCCS Client Health History Form (108 Kb, PDF)
  • BCCS Enrollment Form (74Kb, PDF)
  • BCCS Treatment Form (73 Kb, PDF)
  
  Med-IT User Request Form
  
  • Med-IT User Request Form (70Kb, PDF) Submit to Med-IThelpdesk@dshs.state.tx.us for a username and password.
  • Med-IT New Provider Request Form (19KB, DOC) Submit to Med-IThelpdesk@dshs.state.tx.us
• FY10 Contract Renewal Application Packet & Clinical Cost Worksheet
  • FY10 BCCS Contract Renewal Application Packet (945KB, DOC)
  • FY10 Clinical Cost Worksheet (96KB, Excel)
• Case Management Forms
  This form is used by all DSHS BCCS contractors to document the provision of case management services to clients.
  • English (20KB, PDF)
  • Spanish (20KB, PDF)
  
  Medicaid for Breast and Cervical Cancer (MBCC) Information - formerly Treatment Act
  In Texas, Medicaid for Breast and Cervical Cancer is a special Medicaid program that provides access to cancer treatment services for qualified women. This program was implemented to provide full Medicaid benefits to uninsured women under age 65 that meet eligibility requirements, and are in need of treatment for breast or cervical cancer.
  • Client Referral to the Medicaid Treatment Act (70KB, PDF)
  • Self Referral to the Medicaid Treatment Act (40KB, PDF)
  • Medicaid Treatment Act Qualifying Diagnosis Guide (50KB, PDF)
• Other Forms and Reports
  • BCCS Quarterly Match Report Form (45Kb, MS Word)
  • BCCS Quarterly Match Report Instructions (62Kb, MS Word)
  • BCCS Program Narrative Report (76Kb, MS Word)
  • State of Texas Purchase Voucher (B13) - FY07 (51Kb, MS Word)
  • BCCS Monthly Summary Form - FY07 (51Kb, MS Word)
  • Annual FSR 270 (234Kb, PDF)
• Notice of Grant Awards
  • BCCS Notice of Award Issued 5-13-2010 (1.6 MB, PDF)
  • BCCS Notice of Award Issued 9-24-2010 (142 KB, PDF)

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Contractor Vouchers and Reporting

• Epilepsy Voucher and Reporting Procedures (28K, Excel)
• Primary Health Care Voucher and Reporting Procedures (27K, Excel) Updated 2/18/09
• Title V Maternal and Child Health and Reporting Procedures (23K, Excel)
• Title V Family Planning Voucher and Reporting Procedures (19K, Excel)
• Title X Family Planning Voucher and Reporting Procedures (27K, Excel)
• Title XX Family Planning Voucher and Reporting Procedures (19K, Excel)

• Form #B-13, State of Texas Purchase Voucher
  Purpose: To request monthly reimbursement using a State of Texas Purchase Voucher.
  • Form #B-13 (51 KB, Word format)
  • Form #B-13 instructions (16 KB, PDF format)

• Form #B-13X, Supporting Schedule for Title X Reimbursement Vouchers
  Purpose: Supporting schedule to be completed and submitted with Title X Reimbursement Vouchers
  • Form #B-13x (45 KB, Excel format)

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Epilepsy

• DSHS Funding Source Worksheet – Worksheet Instructions  (20 KB, Word)
• FY12 Epilepsy Quarterly Report Form (34Kb, XLS)
  

Family Planning

•     Forms
• For contracts ending March 31, 2013
  • 2025 DSHS Family Planning Eligibility Screening Form
    English | Spanish (15Kb, PDF)
  • 2025 DSHS Family Planning Eligibility Screening Form Instructions
    English | Spanish (20Kb, PDF)
• Procedure Codes
  • Family Planning Procedures Codes for contracts ending March 31, 2013
    • Family Planning Procedures Codes - DSHS Family Planning (35Kb, PDF)
• Income Guidelines and Sample Sliding Fee Scales
• 2011 Federal Income Poverty Levels (45 Kb, PDF)
• Sliding Fee Scale for contracts ending March 31, 2013
  • DSHS Family Planning Sliding Fee Scales (42Kb, PDF)
• Elgibility Documents
  • DSHS Funding Source Application - English/Spanish (27Kb, PDF)
  • DSHS Funding Source Worksheet (26Kb, PDF)
  • DSHS Funding Source Worksheet Instructions  (502Kb, PDF)
• Family Planning Annual Report Materials
  • Family Planning Forms and Instructions (6Kb, PDF
  • FPAR Forms Only (Excel)
  • FPAR Forms Only (Word)

External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services.

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FY11 Quality Management Review Tools and Instructions

• FY11 Quality Management Review Tools and Instructions

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Primary Health Care

• Eligibility/Screening Forms and Documents
• Other Forms and Reports
• Eligibility/Determination Screening Forms and Documents
• DSHS Funding Source-Application for Healthcare Assistance & Instructions (EF05-13229)  (97 Kb, MS Word)
• DSHS Funding Source Worksheet  (82 Kb, MS Word)
• DSHS Funding Source Worksheet – Worksheet Instructions (20Kb, MS Word)
• Statement of Applicant's Rights & Responsibilities (103 Kb, PDF)
• Presumptive Eligibility Form (Form 102) (84 Kb, MS Word)
• Presumptive Eligibility Form Instructions (51Kb, PDF)
• Notice of Eligibility Form (97 Kb, MS Word)
• Notice of Eligibility Form Instructions (82 Kb, MS Word)
• Request for Information (Form 104) (432 Kb, MS Word)
• Statement of Self-Employment Income (Form 149) (322 Kb, MS Word)
• Employment Verification (Form 128) (297 Kb, MS Word)
• Other Forms and Reports
• PHC (EXAMPLE) - State Purchase Voucher (FORM B13) (85 Kb, MS Word)
• PHC State Purchase Voucher - NEW (FORM B13) (85 Kb, MS Word)
• PHC - Annual Reporting Form (PHC 300) (54 Kb, Excel)
• PHC - Annual Reporting Form Instructions (43 Kb, DOC)
• PHC Monthly Report Form (PHC-200) (39 Kb, Excel) - Revised 11/04/2011
• PHC Monthly Report Form Instructions (45 Kb, MS Word) - Revised 11/04/2011
• Financial Status Report - Form FSR 269a (55Kb, MS Excel)

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Title V MCH Fee for Service

• Eligibility Determination Forms
• DSHS Funding Source Worksheet – Worksheet Instructions (20 Kb, DOC)
  Funding Source Application: Screening & Eligibility Determination Form (74 Kb, DOC)
• Funding Source Worksheet (93 Kb, DOC)
• Statement of Applicant's Rights & Responsibilities (99 Kb, MS Word)
• Presumptive Eligibility Form (49 Kb, MS Word)
• Notice of Eligibility Form (90 Kb, MS Word)
• Annual FSR 270 (234Kb, PDF)
• Request for Information Application (417 Kb, DOC)
• Statement of Self-Employment Income Form (287 Kb, DOC)
• Employment Verification Form (295 Kb, DOC)
• Other Forms and Reports
  All monthly pay vouchers and reports are located in the Excel workbooks. One workbook for child health and dental services and one for prenatal:
• FY12 and FY11 - Monthly Vouchers
• FY12 Title V MCH Monthly Vouchers and Reports (Child Heath & Dental)(158 Kb, Excel) - September 2011
• FY12 Title V MCH Monthly Vouchers and Reports (Prenatal) (114 Kb, Excel) - September 2011
• FY11 Title V MCH Monthly Vouchers and Reports (Child Heath & Dental)(158 Kb, Excel) - Revised February 2011
• FY11 Title V MCH Monthly Vouchers and Reports (Prenatal) (114 Kb, Excel) - Revised February 2011
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External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services.