Nonemegency Ambulance Prior Authorization …

texas medicaid and children with special Health Care Needs (CSHCN) Services Program Non-emergency Ambulance Prior Authorization Request Submit completed form by fax to: 1-512-514-4205 F00045 Page 1 of 5 Revised Date: 02/01/2018 | Effective Date: 05/01/2018 Prior Authorization Request Submitter Certification Statement I certify and affirm that I am either the Provider, or have been specifically authorized by the Provider (hereinafter " Prior Authorization Request Submitter") to submit this Prior Authorization request.

Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program Non-emergency Ambulance Prior Authorization Request Submit completed form by fax to: 1-512-514-4205

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