TX HHS Form 3036. Preauthorization Request for Conversion Services

The TX HHS Form 3036, "Preauthorization Request for Conversion Services," is a crucial tool for healthcare providers seeking to initiate or modify services for adult mental health patients under the Home and Community Based Services (HCBS) Adult Mental Health (AMH) Program. This form helps streamline the process of obtaining preauthorization for conversion services, ensuring that necessary information is provided and facilitating timely determinations.

To complete this form, providers must select the type of request (new or revised), provide participant information including name, date of birth, CARE ID number, Medicaid number, and Clinical Management for Behavioral Health Services (CMBHS) ID. Additionally, they must supply their own contact information, including provider name, phone number, and email address. The "Contact for Determination" section allows providers to specify the individual or team responsible for receiving notification of the preauthorization determination.

This form should be used by healthcare providers seeking to initiate or modify conversion services for adult mental health patients under the HCBS-AMH Program. By submitting this form, providers can ensure that their requests are properly evaluated and processed in a timely manner. The form can be emailed to [email protected] with the subject line "Request for RM Preauthorization."