Get Family Planning 2017 Claim Form - Tmhp.com

Completing the Family Planning 2017 Claim Form is essential for obtaining funding for family planning services. This guide offers a user-friendly, step-by-step approach to filling out the form accurately and effectively.

Follow the steps to successfully complete the claim form online.

1. Click ‘Get Form’ button to access the Family Planning 2017 Claim Form and open it in your preferred digital editor.
2. In section 1, select the appropriate family planning program by checking the relevant box for V, XIX, or XX. If the provider receives Title X funding, ensure to indicate the level of practitioner in section 28.
3. Enter the billing provider's nine-digit Texas Provider Identifier (TPI) in section 2a, and the optional National Provider Identifier (NPI) in section 2b.
4. Provide the provider's name as registered with TMHP in section 3, followed by the eligibility date in section 4, formatted as MM/DD/CCYY.
5. In section 5, enter the client's family planning number for Title XIX or leave blank if the client is new and has not been assigned one.
6. Fill in patient details in sections 6 through 12, including the patient's name, address, date of birth, sex, and, if applicable, their Social Security number.
7. Indicate patient status in section 11, whether they are a new or established patient, and provide relevant demographic information such as race and ethnicity in sections 13 and 13a.
8. In sections 15 and 15a, report the family income and size based on the eligibility guidelines provided.
9. Complete sections 16 to 22, documenting the patient's reproductive history, primary birth control methods, and any existing insurance coverage details.
10. Enter treatment specifics in sections 29 through 32F, ensuring to provide diagnosis codes, service dates, and charges related to the services rendered.
11. Finally, review all entered information for accuracy, then save your changes, download, print, or share the completed form as needed.

Begin completing your Family Planning 2017 Claim Form online now to ensure timely processing of your claims.