TX HHS Form 3036. Preauthorization Request for Conversion Services

The TX HHS Form 3036, Preauthorization Request for Conversion Services, is a crucial document that helps facilitate the conversion process of adult mental health services. This form is typically completed by healthcare providers or organizations seeking preauthorization for behavioral health services under the Adult Mental Health (HCBS-AMH) Program.

This form requires essential information about the participant, including their name, date of birth, CARE ID number, Medicaid number, and Clinical Management for Behavioral Health Services (CMBHS) ID. Additionally, the requesting provider must provide their own contact information, such as name, phone number, and email address. The form also includes a section for contacting determination notification.

To initiate the preauthorization process, healthcare providers should complete this form and submit it via email to [email protected] with the subject line "Request for RM Preauthorization." A determination will be provided via email to the contact listed below. Key points to note include:

• The form is used for new requests or revised authorizations.
• A staff signature and date are required for internal use only.