Follow the steps to successfully complete the Tdi Texas form online.

1. Click ‘Get Form’ button to obtain the form and open it in the selected editor.
2. Begin by filling out Section I – Submission. Here, you will need to provide the issuer’s name, phone number, fax number, and the date of submission.
3. Proceed to Section II – General Information. Indicate whether you are requesting an urgent or non-urgent review. Specify the request type, whether it is the initial request or an extension, renewal, or amendment.
4. In Section III – Patient Information, enter the patient's name, phone number, date of birth, and member or Medicaid ID number. Specify the subscriber’s name if it differs from the patient's, and select the appropriate gender option.
5. In Section IV – Provider Information, complete the details for both the requesting and service provider or facility, including their names, NPI numbers, specialties, and contact information. If applicable, enter the primary care provider's name.
6. Section V – Services Requested requires you to list the planned service or procedure along with the relevant CPT, CDT, or HCPCS codes. You will also specify the location of the service, such as inpatient or outpatient, including details like start and end dates.
7. Finally, in Section VI – Clinical Documentation, briefly outline the medical necessity and attach any necessary clinical documentation. If the requesting provider prefers direct communication regarding the request, include their direct phone number.
8. After completing all sections, thoroughly review the form for accuracy before saving changes, downloading, printing, or sharing as needed.

Complete your documents online today to ensure a smooth authorization process.