Texas Health and Human Services

The TX HHS Form 5204, Office-based Procedures Performed in an Ambulatory Surgical Center Pre-Authorization Request, is a crucial document for healthcare professionals to complete before performing office-based procedures in an ambulatory surgical center. This form helps solve the problem of ensuring that the necessary pre-authorization is obtained from Texas Health and Human Services (HHS) Breast and Cervical Cancer Services (BCCS) prior to commencing treatment.

The TX HHS Form 5203, Breast MRI Pre-Authorization Request, is a crucial document for healthcare professionals to complete before performing breast magnetic resonance imaging (MRI) procedures. This form helps ensure that patients receive the necessary authorization for their treatment while also streamlining the process for healthcare providers.

The TX HHS Form 5202, Patient Navigation Consent, is a crucial document that helps solve the problem of ensuring patients receiving navigation services understand their ongoing care coordination needs. This form is typically used in situations where patients have abnormal test results or require additional evaluation. The patient navigator or healthcare provider fills out this form to obtain the patient's consent for ongoing assessment and care planning.

The TX HHS Form 5201, Med-IT New Provider Request, is a crucial document for healthcare providers to initiate their partnership with the Breast and Cervical Cancer Services (BCCS) program. This form helps solve the problem of new providers joining the BCCS network by providing essential information about their agency, services, and primary contact details.

The TX HHS Form 5200, Med-IT New User Request, is a crucial document for the Breast and Cervical Cancer Services (BCCS) Program Coordinator. This form enables new users to request access to the Med-IT system, allowing them to document client and billing information, run reports, and access minimum data elements (MDE). The form must be completed and dated by the program coordinator.

The TX HHS Form 5156, Referral Checklist, is a crucial tool for ensuring that necessary information is gathered and submitted to facilitate the guardianship process. This form helps solve the problem of incomplete or missing data by providing a comprehensive checklist of required documents and information.

The TX HHS Form 5110, Youth Prevention Universal Program Participation Letter, is a consent form that helps solve the problem of ensuring parental/guardian approval for their child's participation in a tested and proven prevention program. The form is typically used by parents/guardians who want to enroll their youth in this program, which aims to empower youths to resist substance use and misuse, improve life skills, and make healthy choices.

The TX HHS Form 5109, Youth Prevention Universal Parent/Guardian Opt-Out Signature, is a crucial document that helps parents or guardians exercise their right to opt-out of the Select Curriculum program for their youth. This form is specifically designed for the Youth Prevention Universal Program and must be signed and returned if you do not wish your child or family to participate in this program.

The TX HHS Form 5108, Youth Prevention Universal Family Focused Participation Letter, is a consent form designed to engage youths and their families in activities that promote healthy communication and strengthen the family unit. This form helps solve the problem of ensuring parental/guardian awareness and participation in prevention programs, typically used in situations where organizations partner with schools or community sites to provide tested and proven prevention programs.

The TX HHS Form 5107, Parent/Guardian Consent Signature, is a crucial document that helps solve the problem of obtaining parental consent for youth participation in specific programs. This form is typically used by parents or guardians who want to give their consent for their child to participate in the Select Curriculum program offered by the Youth Prevention Program.