Clinics and Other Outpatient Facility Services Handbook - TMHP

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TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 - JANUARY 2013 OP.1 Community and Migrant Health Center Affiliation Affidavit Community and Migrant Health Center Affiliation Affdavit Organization: ____________________________________________________________ Doing Business As: __________________________________________________________________ Federally Qualified Health Center (FQHC) Site / National Provider Identifier (NPI): __________ (where applicable) Affiliation The FQHC does not have an Affiliate Agreement at the site. The FQHC has an Affiliate Agreement at the site. The Affiliation Agreement has been submitted and approved by the Bureau of Primary Health Care (BPHC). The Affiliation Agreement has been submitted and is pending approval by BPHC. The Affiliation Agreement has not been submitted to BPHC. Name and Type of proposed Affiliate Organization(s) or provider: ___________________________ _________________________________________________________________________________ Affiliate Provider NPI: _______________________________________________________________ (where applicable) Signature of Governing Board Chairperson Date PLEASE LIST ALL ATTACHMENTS: PRINT, SIGN, AND MAIL TO: The Texas Medicaid & Healthcare Partnership ATTN: Provider Enrollment PO Box 200795 Austin, TX 78720-0795 11/15/2011 OP-44 CPT ONLY - COPYRIGHT 2012 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CLINICS AND OTHER OUTPATIENT FACILITY SERVICES HANDBOOK OP.2 Newborn Child or Children (Form 7484) MAIL FORM TO: Texas Health and Human Services Commission Data Integrity 952-X PO BOX 149030 Austin, TX 78714-9030 Date Rec’d in Data Integrity PURPOSE: ACTION: This form is to be used by BIRTHING CENTERS ONLY to report the birth of a child of a mother currently eligible under the Medicaid program of the Texas Health and Human Services Commission (HHSC). All data items below must be completed to avoid delay in future medicaid claims payments. If the child’s FIRST name is unknown at the time this form is completed, the last name will suffice and must be shown. To avoid delay in your receiving notice of the Medicaid client number of the newborn child, please complete this document and submit it to HHSC within 5 days after the birth of the child. The 5 days is a guideline and is not mandatory. Notice of the assigned client number will be promptly mailed to you for use in submitting the child’s Medicaid claim. To avoid delay in processing the child’s Medicaid claims, please retain all Medicaid claims of the newborn child until you receive a client number for the child. All newborn claims should then be submitted to TMHP using the newly assigned client number. Mother’s Name (Last, First, MI) Admission Date (mm/dd/yy) Mother’s Medicaid client No. Mother’s Mailing Address--Street Mother’s D.O.B. (mm/dd/yy) Mother’s Medical Record No. City, State, ZIP Child’s Name (Last, First, MI) Sex ❏ M ❏ F Child’s DOB (mm/dd/yy) Child’s Medical Record No. Child’s Name (Last, First, MI) Sex ❏ M ❏ F Child’s DOB (mm/dd/yy) Child’s Medical Record No. Child’s Name (Last, First, MI) Sex ❏ M ❏ F Child’s DOB (mm/dd/yy) Child’s Medical Record No. Has the mother relinquished her rights to the newborn child? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❏Yes ❏No If “Yes,” give date of relinquishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ______________ Certified Midwife Birthing Center Name Birthing Center Address -- Street Certification No C N M 0 0 Completed By (please type or print) TPI City, State, ZIP Birthing Center Telephone No. ( ) Date Form Mailed OP-45 CPT ONLY - COPYRIGHT 2012 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

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