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

The TX HHS Form 1143, Cystic Fibrosis Treatment Agents Prior Authorization Request (CSHCN), is a crucial document for healthcare providers to obtain prior authorization for cystic fibrosis treatment agents. This form helps solve the problem of securing necessary approvals for patients with cystic fibrosis who require specific treatments. The form is typically completed by prescribing physicians and other healthcare providers who need to request approval for treatment agents such as Pulmozyme, Inhaled Tobramycin (TOBI), Cayston, or Kalydeco.

The form requires the provider to provide patient information, including CSHCN ID, patient name, date of birth, gender, and address. Additionally, the provider must check the appropriate statement regarding medical necessity and note dosage for each treatment agent being requested. The form also includes space for the prescribing physician to confirm the accuracy of the provided information by signature.

Key features of this form include the requirement for medical necessity statements and dosage information for each treatment agent. Providers should complete the form and fax or mail it to the CSHCN Services Program. It is essential to note that the information contained in this facsimile transmission is confidential and intended for the exclusive use of the addressee named above.

• The form is used by prescribing physicians and other healthcare providers to request prior authorization for cystic fibrosis treatment agents.
• The form requires patient information, including CSHCN ID, patient name, date of birth, gender, and address.
• The provider must check the appropriate statement regarding medical necessity and note dosage for each treatment agent being requested.