Get Tp1 Medicaid Form

Filling out the Tp1 Medicaid Form online can be a straightforward process if you have clear instructions. This guide will walk you through each section of the form, ensuring you understand what information is required for a successful submission.

Follow the steps to complete the Tp1 Medicaid Form accurately

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin the form by entering your Medicaid Number and CSHCN Number at the top of the page. This information identifies your case within the Medicaid system.
3. Fill in the Client Name and Date of Birth fields accurately. Ensure that the date is formatted correctly as MM/DD/YYYY.
4. Provide the telephone number and address of the client to ensure proper communication.
5. Answer the question regarding whether the child has received therapy in the last year from the public school system by checking the respective box.
6. Indicate the Date of Initial Evaluation and list the therapy types needed: Physical Therapy (PT), Occupational Therapy (OT), Speech Language Pathology (SLP) by checking the appropriate boxes.
7. Attach the required copy of the initial evaluation. Ensure it is ready before submitting the form.
8. Fill in the ICD-9 Code/Diagnosis and the Date of Onset to provide context for the therapy request.
9. Select the Category of Therapy Being Requested by checking the relevant box for options such as Pre-surgery or New Condition.
10. Clearly indicate the dates for the service requested along with the frequency of service per week or per month, ensuring that service dates do not exceed six months.
11. Include any necessary Procedure Codes for therapy services, if applicable.
12. The form requires signatures from the specialist, physician, and relevant therapists. Ensure that each person signs and dates the form appropriately.
13. Enter all relevant Provider Information, including name, telephone, fax, and address.
14. Complete the Medicaid Identifying Information, including TPI, NPI, Taxonomy, and Benefit Code.
15. Check the CSHCN Identifying Information fields and answer the office use questions where necessary.
16. Once all sections are filled, review your entries for accuracy. Save changes, download, print, or share the form as needed.

Begin completing your Tp1 Medicaid Form online today to ensure the timely processing of your request.