Workers' comp, prior authorization, Medicaid, parking and paratransit, school, WIC, guardianship and utility forms from Texas agencies, with who completes each one.
Texas sends clinicians forms from TDI's Division of Workers' Compensation, TMHP for Texas Medicaid, TxDMV, the UIL and a long list of other agencies. The ones practices meet most are the DWC073 Work Status Report, the Texas Standard Prior Authorization Request Form for Health Care Services (NOFR001), the VTR-214 disability placard application and the UIL Pre-participation Physical Evaluation. This hub lists 58 forms, from Houston, Dallas, Austin and San Antonio paratransit forms to the statewide Physician's Certificate of Medical Examination for guardianship.
Several have strict signing rules. A VTR-214 placard signature must be notarized unless an original prescription goes with it. The ERS 2.12 disability statement must be signed by an MD or DO in front of a notary and mailed as an original. The utility critical care application counts only when the physician sends it to the utility. Texas Medicaid forms go through TMHP PA on the Portal or by fax, and deaths are certified online in TxEVER. 10 of these forms have a Spanish version, including the DWC073.
Reporte de Estado de Trabajo
Reports whether the injured employee can return to work without restrictions, with listed activity restrictions, or not at all, and the expected dates.
Certifies whether the injured employee has reached clinical or statutory maximum medical improvement (MMI) and assigns any permanent impairment rating.
Asks DWC for an interlocutory order so a denied, previously prescribed non-formulary drug can continue while independent review is pending.
Records a designated doctor's findings on extent of injury, disability, return to work and other issues other than MMI/impairment that DWC ordered the exam to address.
Solicitud para una revisión por parte de una Organización de Revisión Independiente
Requests independent medical-necessity review after a carrier or URA denies preauthorization or payment for health care services, including workers' compensation.
Attending physician's statement used by the TRS Medical Board to certify that a member is mentally or physically disabled from further performance of duty and that the disability is probably permanent.
MD/DO documents diagnoses (no ICD codes), history, functional and environmental limits, and whether the condition is likely permanently incapacitating for state employment and other occupations, for ERS occupational or non-occupational disability retirement.
TCDRS-32Attending physician's findings, physical and mental limitations and certification whether a TCDRS member is incapacitated from any gainful occupation, likely permanently (and whether duty-related), for the TCDRS Medical Board.
Eye specialist records acuity without/with present glasses and best correction, color perception and eye conditions for an applicant referred after failing the DPS vision test.
Packet (waiver application, Medical Evaluation Summary and physical examination form) for an intrastate commercial driver with a limb impairment to obtain a Texas limb waiver.
Physician or psychiatrist certifies a health condition that may impede communication with a peace officer so 'Communication Impediment' or 'Deaf or Hard of Hearing' is printed on the Texas DL/ID (Transportation Code 521.142(h)).
Licensed medical professional certifies a permanent or temporary disability (Transportation Code 681.001: mobility or vision) for a disability placard and/or license plates.
Treating provider's verification of diagnoses, visual acuity, mobility devices and hypertension clearance for MetroAccess ADA paratransit eligibility in Austin.
Clinician verification of diagnoses, onset dates and mobility aids that prevent the applicant from using DART bus and rail, required with the ADA paratransit certification form.
Aplicación de Servicio de VIAtrans
Medical professional's description of the disability and functional limits for VIAtrans ADA paratransit eligibility in San Antonio/Bexar County.
METRO 0447-20Doctor's or health professional's description of what prevents the applicant from using METRO bus and rail, required for METROLift ADA paratransit eligibility.
Physician's answers on seizure/epilepsy diagnosis, last seizure, type and frequency to decide DART ADA paratransit eligibility for applicants with seizure disorders.
Eye doctor's verification that the applicant is legally blind in both eyes (fields/acuity, prognosis) for DART ADA paratransit eligibility.
Medical professional certification of a qualifying disability (per FTA reduced-fare criteria) for a VIA Reduced Fare ID.
Verification by a local intellectual/developmental disability authority or clinician/therapist of a behavioral health or intellectual disability diagnosis for DART ADA paratransit eligibility.
Prescribing provider's order and medical necessity statement for Texas Medicaid home health DME and medical supplies.
F00139Requests Texas Medicaid prior authorization for outpatient PT, OT and ST evaluations and treatment.
Prior authorization request for Comprehensive Care Program (EPSDT/Texas Health Steps) services, equipment and supplies for Medicaid clients under 21.
Physician-signed plan of care used to prior authorize Texas Medicaid home health skilled nursing, aide and therapy visits.
Requests Texas Medicaid special medical prior authorization for procedures and services that require PA (e.g., certain surgeries, transplants, bariatric surgery).
Seating assessment and medical justification for manual/power wheelchairs, scooters and strollers under Texas Medicaid CCP or home health.
Prescriber documents qualifying oxygen saturation/ABG results and orders for home oxygen equipment and supplies.
Physician's ear examination and medical clearance for a Texas Medicaid hearing aid evaluation and fitting.
Records the state-required vision screening for children in school/child care and the follow-up eye examination after a failed screening.
Health care professional's recommendation allowing an infant in a licensed child care operation to sleep in a position or equipment other than on the back in a crib.
Medical history and physical exam clearance required before a Texas public-school student may practice or compete in UIL athletics or marching band.
Documents physician clearance and completion of the graduated return-to-play protocol after a concussion, as required by Texas Education Code ch. 38 (Natasha's Law).
Physician certificate that a required vaccine would be injurious to the health and well-being of the student or a household member, exempting the student from Texas school/child care requirements.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
EF16-03-13158Medical request for WIC to issue metabolic formula/medical foods for an inborn error of metabolism.
Statewide electronic registrar in which Texas medical certifiers certify cause of death and fetal death records.
25 TAC §157.25(h)(2) figureStatutory standardized order (Health & Safety Code Ch. 166) directing EMS and other out-of-hospital professionals not to initiate CPR and related resuscitation.
Medical evidence required to file an adult guardianship application (Estates Code §1101.103): diagnosis, severity, prognosis, mental functioning, capacity for specific decisions and least restrictive placement.
Registered physician enters the patient's low-THC cannabis prescription (dosage, amount, method) and the patient record in CURT so a licensed dispensing organization can fill it.
Mandated report of suspected abuse, neglect or exploitation of a child, or of an elderly person or adult with a disability, to DFPS.
Initial provider report of a suspected or confirmed case of a Texas notifiable condition to the local or regional health department.
Provider case report of syphilis, gonorrhea, chlamydia, chancroid and other reportable STIs, with treatment and partner information for disease intervention.
DSHS 13-13674Provider case report of HIV infection or AIDS in a patient aged 13 or older for state HIV surveillance.
Physician certifies that a resident depends on an electric-powered medical device to sustain life (critical care) or has a serious condition needing electric devices or heating/cooling (chronic condition), so the transmission and distribution utility grants the status and its notice/disconnection protections.
Solicitud del Programa de Cuidados Críticos
Attending physician certifies that a patient at the residence requires electric-powered medical equipment (or electric heating/cooling) so the household gets extra time to pay under CPS Energy's Critical Care program.
Physician certifies that a Harris County homeowner is disabled (unable to engage in substantial gainful activity for 12+ months, or blind 55+) for the Texas disability residence homestead exemption.
Health care provider certifies a physical or mental health condition that impedes communication so a notation is added to the vehicle registration record for law enforcement.
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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The patient's physician, with a Texas Medical Board license number, on Part 2 of page 3 of the PUCT Application for Chronic Condition or Critical Care Residential Customer Status. Critical care means a resident depends on an electric-powered device to sustain life; chronic condition covers serious conditions that need electric devices or heating and cooling. The physician faxes or emails pages 2 and 3 directly to the utility. CPS Energy in San Antonio uses its own form.
Diagnosis, severity, prognosis, mental functioning, the person's capacity for specific decisions and the least restrictive placement. A physician licensed in Texas completes sections 1 to 11, and the examination must be within 120 days of filing. The certificate goes to the applicant's attorney, who files it with the guardianship application in the county probate court. The statutory probate courts adopted the form for statewide use; a 2023 revision also allows psychologists and APRNs.
For fee-for-service, yes. Service-specific TMHP forms still apply, such as the F00030 order for home health DME and supplies, the F00139 for PT, OT and speech therapy, the F00012 for CCP services for clients under 21 and the F00087 for special medical prior authorization. Submit them through TMHP PA on the Portal or by fax. Medicaid and CHIP managed care organizations must accept the standard NOFR001, and they require the same Title XIX form for DME and supplies.
Only a physician, MD or DO, registered and licensed to practice in the United States. Texas has no state form. The physician writes a signed statement that a required vaccine would be injurious to the health and well-being of the student or a household member, and the school or child care facility keeps it. It is valid for one year from signature unless the physician states a lifelong condition.