Educational Materials
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Materials for Title X and XX Family Planning
Contractors
- Family
Planning Procedures Codes for Title V and XX
(22Kb, PDF, Viewing Information)
- CY05
Family Planning Annual Report Forms and Instructions
(462Kb, PDF, Viewing Information)
- Forms
- Revised 2025 Title X and XX Family Planning Eligibility Screening Form (Revised 9/07)
(15Kb, PDF, Viewing Information)
- Revised 2025 Title X and XX Family Planning Eligibility Screening Form Instructions (Revised 9/07)
(20Kb, PDF, Viewing Information)
- Sterilization
Consent Form (English)
(Spanish)
(85kb/88kb, PDF, Viewing Information)
- Sterilization
Consent Form Instructions (60kb, PDF, Viewing
Information)
- 2017
Claim Form
(35.5Kb, PDF, Viewing Information)
- Family Planning Annual Report Materials
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Materials for Title V Family Planning Contractors
Family
Planning Procedures Codes for Title V and XX
(22Kb, PDF, Viewing Information)
FY07
Screening & Eligibility Determination Form for Medical Services
Assistance - Revised March 2007
(458 Kb, MS Word, Viewing Information)
FY07
Screening & Eligibility Determination Form for Medical Services
Assistance Instructions - Revised March 2007
(372 Kb, MS Word, Viewing Information)
FY07
Statement of Applicant's Rights & Responsibilities
(98 Kb, MS Word, Viewing Information)
FY07
Presumptive Eligibility Form
(49 Kb, MS Word, Viewing Information)
FY07
Notice of Eligibility Form
(90 Kb, MS Word, Viewing Information)
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Educational Materials
Texas Talk: Family Health
Newsletter
Top of Page
.
FY07 Quality Management Review Tools and
Instructions
Core Tool - Items in This Tool Apply to All
DSHS Contactors
BCCS
Case Management
CSHCN
Genetics
Primary Health Care (PHC)
School Health
SDI
Texas Health Steps
Title V - Part A
Title X - XX
WIC
Program tools are used to review contractors monitored by the Quality
Management Branch. Instructions are provided for each program tool.
The instructions follow the number sequence of the appropriate program
tool. Please utilize these tools for self assessment of your agency.
Core Tool (FY07) - Items in this tool apply
to all DSHS contractors.
Core Tool
(87KB, DOC)
Core
Tool Instructions (51KB, PDF)
Child
Abuse Record Review Tool (34KB, DOC)
BCCS (FY07) - Items in this tool apply
to all Breast and Cervical Cancer Control (BCCS) contractors. For more
information visit the BCCS website.
BCCS Tool
(65KB, DOC)
BCCS
Tool Instructions (28KB, PDF)
BCCS
Record Review Tool (50KB, DOC)
CSHCN (FY07)- Items in this tool apply to
Children with Special Health Care Needs (CSHCN) Case Management and
CSHCN Specialty Services. For more information visit the CSHCN
website.
CSHCN
COHP Tool FY07 (145KB, DOC)
CSHCN
COHP Instructions FY07 (43KB, DOC)
CSHCN Clinical Services Tool (146KB, DOC)
CSHCN
Clinical Services Tool Instructions (59KB, PDF)
CSHCN
Case Management Tool (125KB, DOC)
CSHCN
Case Management Tool Instructions (67KB, PDF)
CSHCN
Family Supports and Community Resources Tool (120KB, DOC)
CSHCN
Family Supports and Community Resources Tool Instructions (32KB,
PDF)
Genetics (FY07) - Items in this tool
apply to all Title V-Genetics contractors. For more information visit
the Genetics Program website.
Genetics
Tool (67KB, DOC)
Genetics
Services Tool Instructions (82KB, PDF)
Genetics
Services Clinical Record Review Tool (35KB, DOC)
Genetics
Services Prenatal Clinical Record Review Tool (36KB, DOC)
Eligibility
and Billing Record Review Tool (43KB, DOC)
Primary Health Care (PHC) (FY07) - Items
in this tool apply to all PHC contractors. For more information visit
the Primary Health Care website.
PHC Tool
(77KB, DOC)
PHC
Tool Instructions (38KB, PDF)
Eligibility
and Billing Record Review Tool (43KB, DOC)
Clinical
Record Review Tool (40KB, DOC)
School Health (FY07) - Items in this tool
apply to all School Health (SH) contractors. For more information visit
the School Health
website.
School
Health Tool (62KB, DOC)
School
Health Tool Instructions (44KB, DOC)
Clinical
Record Review Tool (40KB, DOC)
SDI (FY07) - Items in this tool apply to all
Standard Delivery Integration (SDI) contractors.
SDI Tool
(62KB, DOC)
SDI
Tool Instructions (51KB, DOC)
Eligibility
and Billing Record Review Tool (43KB, DOC)
Clinical
Record Review Tool (40KB, DOC)
Texas Health Steps (FY07) - Items in this
tool apply to all Texas Health Steps providers reviewed by QMB. For
more information on Targeted Case Management for Pregnant Women and
Infants and Texas Health Steps Medical Case Management, visit the Texas
Health Steps website.
Texas
Health Steps Tool (45KB, DOC)
Texas
Health Steps Tool Instructions (33KB, DOC)
Clinical
Record Review Tool (40KB, DOC)
Title V - Part A (FY07) - Items in this
tool apply to all Title V-Part A contractors.
Title
V Part A Tool (81KB, DOC)
Title
V Part A Tool Instructions (55KB, DOC)
Eligibility
and Billing Record Review Tool (43KB, DOC)
Clinical
Record Review Tool (40KB, DOC)
Title X-XX - (FY07) Items in this tool
apply to all Title X and Title XX Family Planning contractors. For more
information on Title X-XX visit the Family
Planning website.
Titles
X-XX Tool (105KB, DOC)
Titles
X-XX Tool Instructions (44KB, DOC)
Eligibility
and Billing Record Review Tool (43KB, DOC)
Clinical
Record Review Tool (40KB, DOC)
WIC - (FY07) Items in this tool apply to all
Special Supplemental Nutrition Program for Women, Infants and Children
(WIC) contractors.
Fiscal Self Audit Instructions
(43KB, DOC)
WIC
Tool (170KB, DOC)
WIC Fiscal
Tool (194KB, DOC)
Food Delivery Self Audit
(56KB, DOC)
Explanation for WIC Worksheets (FY07):
These worksheets apply to all WIC contractors. Record reviews must be
documented and include all areas described below. The Recap worksheet
is not required as part of the self audit. Foxfire reports can be used
to obtain participant's names and ensure compliance in the different review
criteria. These reports can be found at http://www.dshs.state.tx.us/wichd/default.shtm
Eligible
(65KB, DOC)
Ineligible
(45KB, DOC)
Midpoint
(41KB, DOC)
Formula
(47KB, DOC)
Employee
(46KB, DOC)
Enhanced
(50KB, DOC)
Referral
(35KB, DOC)
Record
Available (36KB, DOC)
Date
of First Visit (44KB, DOC)
Explanation for WIC Clinical Checklist:
The WIC Checklist applies to all contractors who have a WIC site-monitoring
visit scheduled. To expedite the review, please have the documents that
are listed on the checklist available at the time of the Entrance Conference.
Clinical Checklist
(44KB, DOC)
Primary Health Care
Eligibility/Determination Screening Forms and Documents
FY08 Screening & Eligibility Determination Form for Medical Services Assistance
(97 Kb, MS Word, Viewing Information)
FY08 Screening & Eligibility Determination Form for Medical Services Assistance Instructions
(82 Kb, MS Word, Viewing Information)
FY08 Statement of Applicant's Rights & Responsibilities
(103 Kb, MS Word, Viewing Information)
FY08 Presumptive Eligibility Form
(84 Kb, MS Word, Viewing Information)
FY08 Presumptive Eligibility Form Instructions
(51Kb, MS Word, Viewing Information)
FY08 Notice of Eligibility Form
(97 Kb, MS Word, Viewing Information)
FY08 Notice of Eligibility Form Instructions
(82 Kb, MS Word, Viewing Information)
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Other Forms and Reports
FY '08
FY 08 PHC Monthly Reimbursement Request
(40 Kb, MS Excel, Viewing Information)
FY 08 PHC Monthly Reimbursement Request Instructions
(40 Kb, MS Word, Viewing Information)
FY08 PHC - Annual Reporting Form
(132 Kb, Excel Doc, Viewing Information)
FY08 PHC - Annual Reporting Form Instructions
(39 Kb, MS Word, Viewing Information)
FY08 PHC Monthly Report Form (PHC-200)
(99 Kb, Excel Doc, Viewing Information)
FY08 PHC Monthly Report Form Instructions
(38 Kb, MS Word, Viewing Information)
Financial Status Report - Form FSR 269a
(55Kb, MS Excel, Viewing Information)
FY '07
FY07
PHC-200 Reporting Form
(65 Kb, MS Excel, Viewing Information)
FY07
PHC 300 - Annual Reporting Form - Revised March 2007
(112Kb, MS Word, Viewing Information)
FY07 PHC 301 - Quarterly Reporting Form - Revised March 2007
(63.5 Kb, MS Excel, Viewing Information)
FY
07 PHC Monthly Reimbursement Request - Revised 9/2006
(157Kb, MS Excel, Viewing Information)
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Title V Population-based
Title V MCH Fee for Service
Annual
FSR 270
(234Kb, PDF, Viewing Information)
Eligibility Determination Forms
FY08
Screening & Eligibility Determination Form for Medical Services
Assistance - Revised March 2007
(458 Kb, MS Word, Viewing Information)
FY08
Screening & Eligibility Determination Form for Medical Services
Assistance Instructions - Revised March 2007
(360 Kb, MS Word, Viewing Information)
FY08
Statement of Applicant's Rights & Responsibilities
(98 Kb, MS Word, Viewing Information)
FY08
Presumptive Eligibility Form
(49 Kb, MS Word, Viewing Information)
FY08
Notice of Eligibility Form
(90 Kb, MS Word, Viewing Information)
Other Forms and Reports
All monthly pay vouchers and reports have been combined into on file. One excel workbook for child health and dental, and one for prenatal.
See below:
FY08 Title V MCH Monthly Vouchers and Reports (Child Heath & Dental)
(82 Kb, MS Excel, Viewing Information)
FY08 Title V MCH Monthly Vouchers and Reports (Prenatal)
(80 Kb, MS Excel, Viewing Information)
FY07
Title V MCH Monthly Vouchers and reports
(89 Kb, MS Excel, Viewing Information)
.