Texas Health Steps Provider Outreach Referral Form

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The Texas Health Steps Provider Outreach Referral form replaced the Texas Health Steps Missed Appointment Referral form as of April 1, 2013. This new form should be used by all Texas Health Steps (THSteps) providers who submit a referral on behalf of a THSteps patient who needs assistance:

  • Scheduling a follow-up appointment.
  • Rescheduleing a missed appointment.
  • Scheduling transportation to an appointment.
  • With other outreach services.

The following limitations and restrictions apply to the use of the THSteps Provider Outreach Referral form:

  • Only one referral form can be used for up to 2 patients in a household; if there are more than 2 patients in the same household, an additional referral form must be used.  
  • Referrals should not be submitted for patients who are 21 years of age or older, or are insured by the Children’s Health Insurance Program (CHIP).

The links below can be used to download the referral form and an instruction guide for completing the form. The referral form is available in either Microsoft Word or Portable Document Format (PDF), and can be completed by hand or electronically online and faxed using the cover sheet included with the form.

THSteps providers who have questions about this new referral form, or need information about the THSteps Provider Outreach Referral Service, should contact the appropriate THSteps Provider Relations representative in their region. The names and contact information of the representatives can be found at http://www.dshs.state.tx.us/thsteps/regions.shtm

Texas Health Steps Provider Outreach Referral Form [Word 133KB] 
Texas Health Steps Provider Outreach Referral Form [PDF 1.01MB] 

Instructions [PDF 141KB] Text only

Last updated January 30, 2014