DSHS Community Health Services Forms

Do you need 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

Med-IT User & Provider Forms

Med-IT User & Provider Forms are located on the BCCS Med-IT Information page.


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. Click here to access MBCC information and forms

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Contractor Vouchers and Reporting

  • Please contact the individual programs for the HHSC Voucher Form 4116
  • The current Financial Status Report Form - FSR 269a (GC-4a) may be found on this page: Client Services Contracting Forms  
     

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Epilepsy 



 

Family Planning     

External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services.

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Primary Health Care




Title V MCH Fee for Service

(File Format Viewing Information)
External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services.

Last updated April 4, 2018