TX HHS Form 5205. Breast and Cervical Diagnostic Procedure Complication Reimbursement Request

The TX HHS Form 5205, Breast and Cervical Diagnostic Procedure Complication Reimbursement Request, is a crucial document for healthcare providers to seek reimbursement for complications arising from breast and cervical diagnostic procedures. This form helps solve the problem of seeking financial compensation for medical services provided to patients who experience complications following these procedures.

The form is typically completed by case managers, patient navigators, or contact persons who are responsible for providing medical care and services to clients. Key features of this form include required information such as client details, procedure type, and date of service. The form also includes a section for listing medical care and services received by the client following the complication.

When completing the form, healthcare providers must provide detailed information about the client's condition, including the type of procedure that led to the complication. This information is essential for processing reimbursement requests. To submit the form, healthcare providers should email it along with supporting documentation to [email protected].

• The form is used to seek reimbursement for complications arising from breast and cervical diagnostic procedures.
• Required information includes client details, procedure type, and date of service.
• The form must be completed by case managers, patient navigators, or contact persons.