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DSHS Family and Community Health Forms Home

Do you need a to submit a form for your particular service? The forms home page has every form Family and Community Health staff and contractors will need. Just click on the service area you are interested in and the form you need should be listed below.

Breast and Cervical
Contractor Vouchers and Reporting
Epilepsy
Family Planning
FY07 Quality Management Review Tools and Instructions
Primary Health Care
Title V Population-based
Title V MCH Fee for Service

Breast and Cervical

This form is used by all DSHS BCCS contractors to document the provision of case management services to clients.
TWICES Data Collection Tools
These forms are designed to aid in collecting breast and cervical data to be entered into TWICES by your agency staff. They may be used as a back-up data collection method if TWICES is unavailable, or may be used for data entry in batch form after the client has been seen. 

The tools for breast cancer and cervical cancer are formatted to reflect the stepwise flow of data entry into the TWICES screens and should assist clinic staff in data entry.  There is a prompt in each section that denotes where in TWICES this data will be entered.

Medicaid for Breast and Cervical Cancer (MBCC) Information - formerly Treatment Act

In Texas, Medicaid for Breast and Cervical Cancer is a special Medicaid program that provides access to cancer treatment services for qualified women. This program was implemented to provide full Medicaid benefits to uninsured women under age 65 that meet eligibility requirements, and are in need of treatment for breast or cervical cancer.

Contractor Vouchers and Reporting

Epilepsy

MS Word FIle FY 08 Epilepsy Quarterly Report Form (117 KB, Word format)

MS Word FIle FY 07 Epilepsy Quarterly Report Form (88 KB, Word format)
PDF Document FY 07 Epilepsy Quarterly Report Instructions (15 KB, PDF format)

Family Planning

  • Materials for Title X & XX Family Planning Contractors
  • FPAR Forms and Instructions
  • Materials for Title V Family Planning Contractor
  • Educational Materials

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    Materials for Title X and XX Family Planning Contractors

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    Materials for Title V Family Planning Contractors

    Adobe AcrobatFamily Planning Procedures Codes for Title V and XX
    (22Kb, PDF, Viewing Information)

    MS Word FIle FY07 Screening & Eligibility Determination Form for Medical Services Assistance - Revised March 2007
    (458 Kb, MS Word, Viewing Information)

    MS Word FIle FY07 Screening & Eligibility Determination Form for Medical Services Assistance Instructions - Revised March 2007
    (372 Kb, MS Word, Viewing Information)

    MS Word FIle FY07 Statement of Applicant's Rights & Responsibilities
    (98 Kb, MS Word, Viewing Information)

    MS Word FIle FY07 Presumptive Eligibility Form
    (49 Kb, MS Word, Viewing Information)

    MS Word FIle FY07 Notice of Eligibility Form
    (90 Kb, MS Word, Viewing Information)

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    Educational Materials

    Texas Talk: Family Health Newsletter

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    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)
    PDF DocumentCore 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)
    PDF DocumentBCCS 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)
    PDF DocumentCSHCN COHP Instructions FY07 (43KB, DOC)
    CSHCN Clinical Services Tool (146KB, DOC)
    PDF DocumentCSHCN Clinical Services Tool Instructions (59KB, PDF)
    CSHCN Case Management Tool (125KB, DOC)
    PDF DocumentCSHCN Case Management Tool Instructions (67KB, PDF)
    CSHCN Family Supports and Community Resources Tool (120KB, DOC)
    PDF DocumentCSHCN 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)
    PDF DocumentGenetics 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)
    PDF DocumentPHC 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)
    PDF DocumentSchool 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)
    PDF DocumentSDI 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)
    PDF DocumentTexas 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)
    PDF DocumentTitle 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)
    PDF DocumentTitles 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

    MS Word FIle FY08 Screening & Eligibility Determination Form for Medical Services Assistance
    (97 Kb, MS Word, Viewing Information)

    MS Word FIle FY08 Screening & Eligibility Determination Form for Medical Services Assistance Instructions
    (82 Kb, MS Word, Viewing Information)

    MS Word FIle FY08 Statement of Applicant's Rights & Responsibilities
    (103 Kb, MS Word, Viewing Information)

    MS Word FIle FY08 Presumptive Eligibility Form
    (84 Kb, MS Word, Viewing Information)

    MS Word FIle FY08 Presumptive Eligibility Form Instructions
    (51Kb, MS Word, Viewing Information)

    MS Word FIle FY08 Notice of Eligibility Form
    (97 Kb, MS Word, Viewing Information)

    MS Word FIle 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)

    MS Word FIleFY 08 PHC Monthly Reimbursement Request Instructions
    (40 Kb, MS Word, Viewing Information)

    FY08 PHC - Annual Reporting Form
    (132 Kb, Excel Doc, Viewing Information)

    MS Word FIleFY08 PHC - Annual Reporting Form Instructions
    (39 Kb, MS Word, Viewing Information)

    FY08 PHC Monthly Report Form (PHC-200)
    (99 Kb, Excel Doc, Viewing Information)

    MS Word FIleFY08 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)

    MS Word FIleFY07 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

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      Last Updated October 31st, 2007

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