DSHS Community Health Services Forms

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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

BCCS Data Collection Tools

Med-IT User Request Form


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.
  • Form #B-13X, Supporting Schedule for Title X Reimbursement Vouchers
    Purpose: Supporting schedule to be completed and submitted with Title X Reimbursement Vouchers

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Epilepsy


Family Planning    

Elgibility Documents

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

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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 14, 2014