Corrected Claim Form
Clean Claim Elements
CMS 1500 02-12 Claim Form Manual
New CMS 1500 Guidance

Request for a Review by an Independent Review Organization – English
Request for a Review by an Independent Review Organization – Spanish

Fiscal Year 2025 Enhancement for Attendant Compensation- Request for Participation
DME Supplies Form
Demographic Form
W9 Form – Request for Taxpayer Identification Number and Certification
Credentialing Checklist for Organization/Facility
Credentialing Application for Organization
Secondary Locations for Organization
Credentialing & Re-Credentialing Checklist for Physician
Texas Standardized Credentialing Application

ABA Request Checklist
Therapy Request Checklist
CCP Prior Authorization Request Form
STAR/CHIP Pre-Authorization Flyer EFF 10.1.2023
Texas Standard Prior Authorization Form for Health Care Services
Prior Authorization Form – Out of Area Inpatient
Prior Authorization Form – NICU
Provider Guide to In-Lieu of Services
IUD Abandoned Unit Return Form
Case Management Referral Form
Therapy Request Checklist
Behavioral Health Prior Authorization Form

Authorization to Disclose information to PCP
1027 Medicaid Eligibility Form
Specialist as a PCP Request Form
Primary Care Provider Change Request Form

El Paso Health Payer Identifications
Electronic Remittance Advice (835) Request Form
HealthX Fax System