Texas health plans that require prior authorization of a health care service must accept this two-page standard request, including Medicaid, Medicaid managed care, CHIP and state employee plans. Providers fax or mail it to the issuer for services such as procedures, admissions, therapy, home health and DME. TMHP posts it for Texas Medicaid but notes it does not replace required TMHP forms.
The requesting provider or facility completes Sections II through VI and signs if the issuer requires a signature. Section I, the issuer's contact details, may already be filled in on the copy posted on the issuer's website.
Enter the issuer's name, phone and fax, and the date. An issuer may already have entered this information on the copy of the form posted on its website, so use that copy when available. Send the request to the issuer from which you are seeking authorization, never to TDI, the Health and Human Services Commission or the patient's employer.
Mark the review type as non-urgent or urgent, and give the clinical reason for urgency. Urgent review fits a life-threatening condition, a patient currently hospitalized, treatment after stabilization of an emergency, or an acute injury or illness severe or painful enough to risk serious deterioration. Mark the request type as initial or extension, renewal or amendment, with the previous authorization number.
Enter the patient's name, phone and sex (Male, Female, Other or Unknown), the subscriber's name if different, the member or Medicaid ID number, date of birth and group number. These fields let the issuer find the correct coverage, so copy the ID exactly from the member card.
Complete both columns, the requesting provider or facility and the service provider or facility, with name, NPI, specialty, phone and fax; write Same when they match. Give a contact name and phone. If the plan requires a primary care provider, enter the PCP's name and phone, or Same. Sign and date only if the issuer requires it, without a signature stamp.
List each planned service or procedure with its code and start and end dates, and each supporting diagnosis with its description, ICD version and code. Then check the setting: inpatient, outpatient, provider office, observation, home, day surgery or other. Accurate codes and dates matter because the issuer authorizes the specific services and period you list.
For physical, occupational or speech therapy, cardiac rehab or mental health and substance abuse services, give the number of sessions, duration and frequency. For home health, indicate whether the MD signed order and nursing assessment are attached, with visits, duration and frequency. For DME, indicate the signed order and, for Medicaid only, Title 19 certification, and list equipment with HCPCS codes and duration.
Give a brief narrative of medical necessity in this space or in an attached statement, and attach supporting clinical documentation such as medical records, progress notes or lab reports if needed. At the bottom you may add the requesting provider's direct phone number so the issuer can call about missing information; that call is not a peer-to-peer discussion.
Download the current version from the source each time; forms change without notice.
Texas Standard Prior Authorization Request Form for Health Care Services
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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Yes. The instructions list Medicaid, the Medicaid managed care program and CHIP, along with plans for state of Texas employees, most school districts and The University of Texas and Texas A&M Systems, as public issuers that must accept the form alongside commercial issuers when they require prior authorization of a health care service.
No. NOFR001 is for health care services such as procedures, admissions, therapy, home health and DME. Prescription drugs and devices, formulary exceptions, quantity limit overrides and step-therapy exceptions go on the companion Texas Standard Prior Authorization Request Form for Prescription Drug Benefits, NOFR002.
The instructions allow an urgent review for a patient with a life-threatening condition, a patient currently hospitalized, or treatment after stabilization of an emergency condition. You may also request one for an acute injury or illness that the provider judges severe or painful enough to need it to prevent serious deterioration.
No. When the issuer requires the requesting provider's signature, the instructions say a signature stamp may not be used. The signature and date go in the Section IV field for the requesting provider, and they are needed only if the issuer requires them.