TX HHS Form 1143. Cystic Fibrosis Treatment Agents Prior Authorization Request (CSHCN)

The TX HHS Form 1143 is a prior authorization request form for cystic fibrosis treatment agents, specifically designed for providers to obtain approval from the Children with Special Health Care Needs (CSHCN) Services Program. The form is intended for use by healthcare professionals who are seeking to initiate or continue therapy with Pulmozyme, Inhaled Tobramycin (TOBI), Cayston, or Kalydeco for patients diagnosed with cystic fibrosis.

This form requires providers to complete patient information, including the CSHCN ID, patient name, date of birth, gender, and address. Additionally, providers must check the appropriate statement regarding medical necessity and note dosage for each treatment agent being requested. The form also includes space for physicians to provide their contact information and confirm the accuracy of the submitted information.

The TX HHS Form 1143 is an essential tool for healthcare professionals seeking to obtain prior authorization for cystic fibrosis treatment agents. As issued by the Texas Health and Human Services (HHS), this form ensures that patients receive necessary treatments while also promoting efficient use of resources within the CSHCN Services Program.