Texas Medicaid's Comprehensive Care Program (CCP) covers medically necessary services for clients under 21, and form F00012 requests TMHP prior authorization for CCP services such as applied behavior analysis, DME, medical supplies, private duty nursing, PPECC and inpatient rehabilitation. A physician meets it when certifying the request in Section F. The provider submits it through TMHP's PA on the Portal or by fax.
The rendering provider, supplier or qualified rehabilitation professional completes Sections A to E, including the request type, diagnosis and medical necessity, and HCPCS lines. The requesting physician or allowed practitioner completes and signs Section F, the Primary Practitioner's Certifications.
Download the current version from the source each time; forms change without notice.
CCP Prior Authorization Request Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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That the client is under 21, plus a service-specific statement: for ABA, a diagnosis of autism spectrum disorder and that ABA is or may be clinically indicated; for DME and supplies, that items are appropriate and safe as prescribed; for private duty nursing or PPECC, that the condition is stable enough for safe delivery under the plan of care.
The version revised June 7, 2023 and effective July 1, 2023. Page 1 carries the Prior Authorization Request Submitter Certification Statement, which the provider accepts by checking We Agree, confirming the information is accurate and kept in the patient's medical record under the Texas Medicaid Provider Procedures Manual.