Submit your prior authorization using TMHP's PA on the Portal and receive request decisions more quickly than faxed requests.
Essential fields: if fields marked with an asterisk are not completed, your prior authorization request will be returned.
Fax requests: must be scanned and data entered before the PA Department receives them, which can take up to 24 hours.
Practitioner signature: signatures from chiropractors and doctors of philosophy (PhDs) will not be accepted.
Stamps: signature stamps and date stamps are not acceptable.
HCPCS codes: HCPCS codes and descriptions must be provided.
| Question | Answer |
|---|---|
| Form Name | F00012 |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 91 |
| Avg. time to fill out | 16 min |
| Edition | Revised 06/07/2023 |
| Effective | 07/01/2023 |
| Matches the agency's file | Yes, checked October 3, 2026 |
| Other names | F00012, CCP Prior Authorization Request Form, CCP form, CCP prior authorization form, Texas CCP prior authorization request form |
| Official source | F00012 (Revised 06/07/2023) CCP Prior Authorization Request Form |
Ccp Prior Authorization Request Form isn’t the one you’re looking for?