Texas Medicaid fee-for-service has required this form since July 1, 2017 for physical, occupational and speech therapy prior authorization, for clients of all ages, initial requests and every recertification. The therapist submits it with the evaluation and the referring provider's order. TMHP authorizes acute therapy for up to 60 days and chronic therapy under the Comprehensive Care Program for up to 180 days.
The treating therapist prepares the form, and each therapist who will deliver services prints, signs and dates it. The requesting (prescribing) provider signs it or supplies a signed and dated order, and the billing provider or agency enters its rendering billing information.
Page 1 is a certification by the provider and anyone authorized to submit for them. Checking We Agree affirms under penalty of perjury that the information is true, complete and kept in the patient's medical record under the Texas Medicaid Provider Procedures Manual, and that prior authorization is a condition of reimbursement, not a guarantee of payment. False or omitted information can lead to termination of Medicaid enrollment.
The top of page 2 lists a separate fax line for each TMHP unit. Send requests for clients from birth through 20 years of age to CCP in any setting. For clients 21 and over, acute therapy in the home goes to Home Health Services and acute therapy in an outpatient setting goes to SMPA.
Enter the client's name, including middle name or initial if known, the 9-digit Medicaid number and date of birth; all three are critical fields. Mark the condition as acute (up to 60-day authorization) or chronic (up to 180-day authorization). Enter treatment diagnoses with ICD-10 codes for the conditions that need therapy, and any other relevant medical diagnoses.
Check office, outpatient, home or other. For services rendered in a PPECC, check the outpatient facility box. Enter the date of the last evaluation or re-evaluation for each discipline, and attach a copy of that evaluation or re-evaluation, or the progress summary for acute therapy, for every discipline you request, along with any other documentation the TMPPM requires.
Use the PT (GP), OT (GO) and ST (GN) lines for each discipline requested. The From date is the day therapy treatment begins and the Through date is the last day requested; both are critical fields. Keep the span within the authorization limit: 60 calendar days for acute conditions, and 180 calendar days for chronic conditions under CCP only.
Enter sessions per week or per month; monthly frequencies are limited to 1, 2 or 3 times a month, and the TMPPM requires extra documentation for 3 or more times a week. Note tapered or variable plans, or a discharge date, in the space provided. Total 15-minute units for time-based codes and encounters for encounter-based codes, labeling each.
List every procedure code requested, including re-evaluation and treatment codes; this is a critical field. Each physical, occupational or speech therapist who will deliver services prints their name, signs and dates on their discipline's line. When a request combines unit-based and encounter-based treatment codes, describe the combination in the tapered-frequency space.
The prescribing provider prints, signs and dates, and enters NPI, license number and the date the client was last seen. The signature certifies a signed Plan of Care with all Texas Medicaid elements and, for clients through age 20, a Texas Health Steps checkup or developmental screening in the last 60 days. Without a signature, attach a signed and dated prescription or order.
The provider or agency billing for therapy enters its name, phone, fax, street address and ZIP+4, tax ID, NPI, taxonomy code and benefit code. Name, street address, ZIP+4, tax ID, NPI, taxonomy and benefit code are critical fields. The address should match the one tied to the NPI or tax ID, and TMHP uses the phone and fax for approvals or to ask for more information.
Download the current version from the source each time; forms change without notice.
Texas Medicaid Physical, Occupational, or Speech Therapy (PT, OT, ST) Prior Authorization 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.
Sources for this guide
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TMHP must receive the initial request no later than five business days from the date therapy services began. If it arrives later, dates of service before the date TMHP receives the request are denied. Recertification requests must arrive before the current authorized period expires, but no earlier than 30 days before.
No. The form may be submitted without the requesting provider's signature and date if it is accompanied by a signed and dated prescription, a dated written order, or a dated documented verbal order. Verbal orders must be co-signed by a practitioner whose scope of practice includes verbal orders.
Acute conditions are authorized for up to 60 calendar days. Chronic conditions are authorized for up to 180 calendar days, under the Comprehensive Care Program only. TMHP uses the date the client was last seen by the prescribing provider to check that an acute condition or exacerbation is within 90 calendar days of the requested therapy.
Requests for acute or chronic therapy for clients from birth through 20 years of age go to the Comprehensive Care Program at TMHP, whatever the practice setting. CCP now processes all requests for children's therapy services, through PA on the Portal, fax or mail.