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  • Mental Health Servicespreauth Form.doc - Mchd-tx

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PRIME DX MENTAL HEALTH SERVICES PRE-AUTHORIZATION REQUEST FORM ONLY ONE REQUEST PER FORM PLEASE FOR MONTGOMERY COUNTY HOSPITAL DISTRICT HCAPCLIENTS ONLY Please complete and submit all requested information.

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Contact support

Attach sufficient clinical information to support medical necessity for services, or your request may be delayed. Fax the completed form to the Prior Authorization Department at 1-800-743-1655.

You may also fax in a prior authorization at 800-391-6437.

Montgomery County Hospital District's mission is to care for the indigent and provide EMS services while protecting the interest of taxpayers and ensuring long-term stability through fund development.

Medicaid Prior Authorization Fax Numbers: Prescription Drugs: 1-833-423-2523. Radiology and Cardiac Imaging: 1-800-784-6864. Musculoskeletal Surgical Procedures: 1-833-409-5393.

By fax. Complete the Texas standard prior authorization request form (PDF). Then, fax the form to 1-866-835-9589.

Note: Some issuers may require more information or additional forms to process your request. If you think more information or an additional form may be needed, please check the issuer's website before faxing or mailing your request. Please fax form to Superior HealthPlan at 1-866-399-0929.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232