TX HHS Form 5203. Breast MRI Pre-Authorization Request

The TX HHS Form 5203, "Breast MRI Pre-Authorization Request", is a crucial document used to request pre-authorization for breast magnetic resonance imaging (MRI) procedures. This form helps healthcare professionals and case managers streamline the process of obtaining approval for breast MRI exams, ensuring that patients receive necessary care in a timely manner.

This form requires essential information from clients, including their name, date of birth, medical history, and physical characteristics. The "History and Physical Information" section is particularly important, as it helps healthcare providers identify potential risk factors or syndromes that may impact the patient's breast health. Additionally, the form asks about recent screening or diagnostic procedures received through the Breast and Cervical Cancer Services (BCCS) program.

The "Procedure Information" section allows healthcare professionals to specify the requested procedure(s), including whether it will be performed in a facility with dedicated breast MRI equipment and staff capable of performing breast MRI-guided biopsies. The form also includes space for clients to provide their contact information, as well as a section for BCCS use only.