TDI Forms

Life, Health & Licensing - HMO

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Texas Standardized Credentialing Application | IRO Forms | Other Forms | URA Forms | Workers' Compensation Health Care Networks Forms

 

Texas Standardized Credentialing Application

TDI Form Number	Description	File Format
LHL234	Application Package	RTF
LHL234	Application Package	PDF
LHL234	Application Package	WORD
LHL234a	Other Professional Degrees A	RTF
LHL234a	Other Professional Degrees A	WORD
LHL234a	Other Professional Degrees A	PDF
LHL234b	Other Post-Graduate Education B	PDF
LHL234b	Other Post-Graduate Education B	WORD
LHL234b	Other Post-Graduate Education B	RTF
LHL234c	Other Work History C	RTF
LHL234c	Other Work History C	PDF
LHL234c	Other Work History C	WORD
LHL234d	Other Current Hospital Affiliations D	WORD
LHL234d	Other Current Hospital Affiliations D	PDF
LHL234d	Other Current Hospital Affiliations D	RTF
LHL234e	Other Previous Hospital Affiliations E	RTF
LHL234e	Other Previous Hospital Affiliations E	PDF
LHL234e	Other Previous Hospital Affiliations E	WORD
LHL234f	Other Practice Locations F	PDF
LHL234f	Other Practice Locations F	WORD
LHL234f	Other Practice Locations F	RTF
LHL234g	Malpractice Claims History G	RTF
LHL234g	Malpractice Claims History G	PDF
LHL234g	Malpractice Claims History G	WORD
LHL396	Credentialing Requirements Checklist Individual Health Care Providers	WORD
LHL396	Credentialing Requirements Checklist Individual Health Care Providers	PDF
LHL397	Credentialing Requirements Checklist Health Care Facilities	PDF
LHL397	Credentialing Requirements Checklist Health Care Facilities	WORD

 

IRO Forms

TDI Form Number	Description	File Format
LHL006	Independent Review Organization Application Application to apply for a IRO Certification	PDF
LHL009	Request for IRO Assignment Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity	WORD
LHL009	Request for IRO Assignment [ En Español ] - Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity	WORD
LHL009	Request for IRO Assignment [ En Español ] - Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity	PDF
LHL009	Request for IRO Assignment Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity	PDF

 

URA Forms

TDI Form Number	Description	File Format
LHL005	URA Application Form Application to apply for a URA Certification	PDF
LHL007	Name Change for Health Care Utilization Review Agent	PDF
LHL009	Request for IRO Assignment Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity	WORD
LHL009	Request for IRO Assignment Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity	PDF
LHL009	Request for IRO Assignment [ En Español ] - Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity	WORD
LHL009	Request for IRO Assignment [ En Español ] - Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity	PDF

 

Other Forms

TDI Form Number	Description	File Format
LHL390	WC Network Biographical Affidavit Form Workers' Compensation Health Care Network Biographical Affidavit	PDF
LHL390	WC Network Biographical Affidavit Form Workers' Compensation Health Care Network Biographical Affidavit	WORD
LHL391	WC Network Application Form Workers' Compensation Health Care Network Application	PDF
LHL391	WC Network Application Form Workers' Compensation Health Care Network Application	WORD
LHL392	WC Network Application Certification Requirements Checklist Workers' Compensation Health Care Network Application Certification Requirements Checklist	PDF

Other Forms

LHL011 - Individual HMO Checklist [PDF]

Used as guide to indicate the mandatory provisions and benefits required in an Evidence of Coverage

LHL012 - Physician/Provider Contract Checklist [PDF]

Used as guide to indicate the mandatory provisions and benefits required in a Provider Contract

LHL252 - Form CCP/Figure 1 Required Disclosure Notice for All Individual HMO Consumer Choice Benefit Plans Issued in Texas [PDF]

Disclosure Notice to Purchase a Consumer Choice Health Benefit Plan for Individual HMO

LHL254 - Form CCP/Figure 1 Required Disclosure Notice for All Group HMO Consumer Choice Benefit Plans Issued in Texas [PDF]

Disclosure Notice to Purchase a Consumer Choice Health Benefit Plan for Group HMO

LHL259 - Transmittal Checklist for HMO Filings [PDF]

Used by companies to submit forms for policy review/approval.

LHL358 - Small Employer Consumer Choice Evidence of Coverage Checklist [PDF]

Checklist

LHL359 - Individual Consumer Choice Evidence of Coverage Checklist [PDF]

Checklist

LHL360 - Large Employer Consumer Choice Evidence of Coverage Checklist [PDF]

Checklist

LHL361 - Workers Compensation Utilization Review Adverse Determination Summary [Excel]

Checklist

LHL380 - Evidence of Coverage Requirements (Small Employer & Conversion Plans) [PDF]

Checklist

LHL381 - Evidence of Coverage Requirements (Large Employer & Conversion Plans) [PDF]

Checklist

LHL385 - Delegated Entities & Delegated Third Parties [PDF]

Checklist

LHL398 - Health Maintenance Organization (HMO) [PDF] | LHL398 - Health Maintenance Organization (HMO) [Word]

Network Access Plan Checklist

LHL399 - Workers' Compensation Health Care Network [PDF] | LHL399 - Workers' Compensation Health Care Network [Word]

NETWORK Access Plan Checklist

LHL402 - Form Health Pool Notice [PDF]

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For more information contact: Hmogrp@tdi.state.tx.us