CSHCN Services Program Physician/Dentist Assessment Form Form T-4 Rev. 08-2015Page 1 of 2

Texas Department of State Health Services

Children with Special Health Care Needs (CSHCN) Services Program

Physician/Dentist Assessment Form

Applicant InformationFirst name: Last name:Middle name:

CSHCN client number (if known):Date of birth:

Medical Information

The applicant meets one of the following definitions:

A person younger than 21 years of age who has a chronic physical or developmental condition that:

• Will last or is expected to last for at least 12 months AND • Results in, or if not treated, may result in limits to one or more major life activities AND • Requires health and related services of a type or amount beyond those required by children generally AND • Has a physical (body, bodily tissue, or organ) manifestation AND • May exist with accompanying developmental, mental, behavioral, or emotional conditions BUT is not solely a delay in intellectual development or solely a mental, behavioral, or emotional condition. A person of any age who has cystic fibrosis.

I certify that the applicant is medically eligible based on the following diagnoses: Yes No

Primary ICD code: Combination Code:

Primary ICD Code Description:

Additional ICD code: Combination Code:

Codes must be at the highest level of specificity.

Additional ICD Code Description:

Instructions: Return the signed form to the applicant or mail to

CSHCN Services Program MC 1938 PO Box 149347 Austin, TX 78714-9347

If you have any questions, call 1-800-252-8023.

Combination Code Description:

Combination Code Description:

Additional ICD code: Combination Code:

Additional ICD Code Description: Combination Code Description:

If filling out prior to 10/1/15, use ICD-9 codes only. If filling out on or after 10/1/15, use ICD-10 codes only.

This form is part of the application to the CSHCN Services Program to be completed by applicant's physician or dentist.

Este formulario forma parte de la Solicitud de Prestaciones del Programa de Servicios CSHCN a cumplimentar por el medico o dentista del solicitante.

Formulario de Evaluación del Médico o Dentista

CSHCN Services Program Physician/Dentist Assessment Form Form T-4 Rev. 08-2015Page 2 of 2

Services, other than medical or dental, you think the applicant may require.

For planning purposes only. Your answers will not affect eligibility decisions.

Physician/Dentist InformationFirst name: Last name:

Specialty: Phone number:

XSignature Date (mm/dd/yy)

Acknowledgement

I understand that by signing below I am stating from my personal knowledge that the facts on this form are true and correct.

If a lack of care will not cause permanent harm OR if the applicant is actively planning to live in an institution, please include any information on complexity or severity of the condition that the CSHCN Services Program should know.

Attach additional pages to this form, if necessary.

Was the applicant born before 36 weeks of gestation? Yes No

Has the applicant spent 14 consecutive days out of the hospital? Yes No

Certification of Needs

Would an inability to get health care cause a permanent increase in disability, pain, suffering, or death? Yes No

NoYesIs applicant's condition a result of a traumatic injury or accident?

Date of trauma or accident: Date of discharge if hospitalized:

NPI #:

Case Management Home Health Mental Health

ZIP code:State:City:

Physician address: