DSHS Community Health Services Forms


Do you need 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.

NEW - Revised Forms

Breast and Cervical

Med-IT User & Provider Forms

Med-IT User & Provider Forms are located on the BCCS Med-IT Information page.

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. Click here to access MBCC information and forms

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Contractor Vouchers and Reporting

  • Form #B-13, State of Texas Purchase Voucher
    Purpose: To request monthly reimbursement using a State of Texas Purchase Voucher. For form B-13 and instructions go to http://www.dshs.state.tx.us/grants/forms.shtm
  • For program specific vouchers and instructions refer to the appropriate program section of this page.

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Expanded Primary Health Care (EPHC)

Expanded Primary Health Care (EPHC) Contractor Billing Resource Guide - posted 1/29/15

Form 102 – Notice of Presumptive Eligibility optional
Form 102A – Notice of Presumptive Eligibility – Instructions

Class D Pharmacy Exemption Request Form (Form # EF05-14426) for Family Planning and EPHC, posted 1/21/15


Form B13 – State Purchase Voucher Revised 9/29/14

B13E - EPHC Categorical Voucher Revised 11/7/14

Reporting Form and instructions for Contractors with an EPHC categorical contract and without a Traditional Primary Health Care (PHC) contract:

FY15 EPHC 275 Report* – Revised 3-17-15 *Please note that it is the same form for both the monthly report and the quarterly report, depending on the month that the report is for; when the month is selected from the drop-down menu for the “Reporting Period”, the appropriate report will appear. 8589993978

FY 15 EPHC 275 Report InstructionsRevised 9-29-14

PHC 350 Annual Report - posted 10/29/14

PHC 350 Annual Report Instructions- posted 10/29/14

Program Promotion-Outreach Quarterly Progress Report- posted 12/9/14


Family Planning     

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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Primary Health Care

Reporting Form and instructions for Contractors with either Traditional PHC contract only or for Contractors with both EPHC and Traditional PHC contracts:

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Title V MCH Fee for Service

(File Format Viewing Information)
External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services.



Last updated April 27, 2015