Form Tp 2 – Fill Out and Use This PDF

The Form TP-2, or Request for Extension of Outpatient Therapy, is a crucial document for seeking continued therapy services under Texas Medicaid & Healthcare Partnership. This two-page form is utilized to request additional therapy sessions for individuals, ensuring that necessary outpatient therapy can proceed without interruption. If you or a loved one requires further treatment, consider filling out Form TP-2 by clicking the button below.

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Form Tp 2 PDF Details

Navigating the healthcare landscape requires an understanding of various forms and documents, especially when it pertains to receiving essential services like therapy. Among these, the TP-2 form stands out as a critical piece in ensuring that individuals, specifically children under the care of Texas Medicaid & Healthcare Partnership, continue to receive the outpatient therapy services they need without interruption. This form, with its detailed sections and careful requirements, functions as a Request for Extension of Outpatient Therapy. It is meticulously designed to cover all aspects of therapy services – from physical therapy (PT), occupational therapy (OT), to speech-language pathology (SLP). Service providers fill out this form to document initial evaluations, therapy categories requested (ranging from developmental anomalies to equipment training), and detailed service dates and frequencies. Additionally, it captures the essence of collaborative care by necessitating the signatures of involved healthcare professionals and indicating specific Medicaid and CSHCN (Children with Special Health Care Needs) information, crucial for processing. The form, which is structured in two pages, seamlessly guides the applicant through providing necessary client details, past therapy information, and specifies the conditions under which therapy is requested, laying a clear path for approval and thus, ensuring continuous care."

Question	Answer
Form Name	Form Tp 2
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	Cochlear, TX, TPI, ADL

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Request for Extension of Outpatient Therapy

(2 Pages) (Form TP-2)

Request for Extension of Outpatient Therapy (Form TP-2)

CCP - Texas Medicaid & Healthcare Partnership		Texas Medicaid & Healthcare Partnership
PO Box 200735				CSHCN
Austin TX 78720-0735				PO Box 200855
1-800-846-7470			Austin TX 78720-0855
CCP FAX: 1-512-514-4212		1-800-568-2413 or 1-512-514-3000
			FAX: 1-512-514-4222

Medicaid Number:		CSHCN Number:
Client Name:		Date of birth:	/ /		Telephone:
Client Address:
Has the child received therapy in the last year from the public school system?			□ Yes	□ No
Date of Initial Evaluation	PT	OT				SLP
A copy of the initial evaluation must be attached

ICD-9 Code/Diagnosis:

Date of onset:

Category of Therapy Being Requested

PT/OT for:

□ Developmental anomalies

□ Pre-surgery

□ Post-surgery

Date of surgery

□ Cast Removal

Date Removed

□ Serial Casting

□ Acute Episode of Chronic Condition

□ New Condition

□ Specialty Clinic

□ Home Program

□ ADL (activities of daily living)

□ Equipment Assessment

□ Equipment Training

Speech for:

□ Craniofacial

□ Developmental Anomalies

□ New Condition

□ Post Cochlear Implant

Check the service requested, indicate the date(s) of service and frequency per week or month:

Dates of service cannot exceed six months. If possible, end requested date of service on the last day of the month.

Service Type		Service Date(s)			Frequency per week	Frequency per month
Service Type	From:			To:
	From:			To:
□ PT	/	/	/	/
	/	/	/	/

□ OT	/	/	/	/
	/	/	/	/

□ SLP	/	/	/	/
□ SLP

Procedure code(s) for therapy services:

Specialist	Name	Signature
Physician
PT Therapist
OT Therapist
SLP Therapist

Date Signed

/	/
/	/
/	/
/	/

Provider Information

Name:	Telephone:	Fax:

Address:

Medicaid Identifying Information

TPI:

NPI:

Taxonomy:

Benefit Code:

CSHCN Identifying Information

TPI:

NPI:

Taxonomy:

Benefit Code:

FOR OFFICE USE ONLY:

Medicaid □ Yes □ No

HMO □ Yes □ No

Restrictions:

FORM TP-2

Page 1 of 2

EFFECTIVE DATE_07302007/REVISED DATE_06012007

PAN#	Valid	To
Medicaid Number:		CSHCN Number:
Client Name:			Date of birth:	/	/
Current Functional Status:

New Treatment Goals:

Prior Dates of Service:	from	/	/	to	/	/

Prior Functional Status:

Prior Treatment Goals:

Prior Treatment Provided:

FORM TP-2

Page 2 of 2

EFFECTIVE DATE_07302007/REVISED DATE_06012007

How to Edit Form Tp 2 Online for Free

You can fill in CSHCN instantly with our online tool for PDF editing. FormsPal is devoted to giving you the ideal experience with our editor by constantly releasing new capabilities and improvements. Our editor has become a lot more intuitive thanks to the newest updates! So now, editing PDF forms is simpler and faster than ever. In case you are looking to get started, this is what it will require:

Step 1: Just hit the "Get Form Button" in the top section of this page to open our form editing tool. Here you will find everything that is required to work with your document.

Step 2: This tool lets you change your PDF file in many different ways. Improve it with customized text, correct what is already in the document, and add a signature - all when you need it!

It is straightforward to complete the form using this practical guide! Here's what you need to do:

1. While submitting the CSHCN, make sure to include all needed fields in the associated section. This will help facilitate the work, enabling your information to be processed efficiently and accurately.

2. Just after the last part is done, go on to enter the applicable details in all these: Client Information, Client name, CSHCN Services Program number, Date of birth, Client Address, Does the client receive therapy, If yes please indicate in the, Diagnosis Codes, Evaluation or Re Evaluation Summary, Date of evaluation or reevaluation, Service Request Indicate procedure, Procedure Code, Modifier, From Date, and Date.

Be extremely mindful when completing Evaluation or Re Evaluation Summary and Date, since this is the section in which many people make some mistakes.

3. The following segment is about Requesting physician name, Physician signature, PT name, OT name, SLP name, PT signature, OT signature, SLP signature, NPI, Date, Date, Date, Date, Rendering Provider Information and, and Rendering provider name - fill out all these fields.

CCP completion process explained (step 3)

4. This specific paragraph comes next with these particular blank fields to enter your particulars in: Client Information, Client name, CSHCN Services Program number, Functional Status Goals and, Current functional status, and New treatment goals.

CCP conclusion process detailed (step 4)

5. To finish your form, this particular segment has a number of extra blank fields. Entering Prior dates of service, From date, To date, Prior functional status, Prior treatment goals, and Prior treatment provided will wrap up everything and you'll surely be done in a tick!

Step 3: Ensure the information is right and just click "Done" to finish the task. Join us now and easily use CSHCN, all set for downloading. Every single edit made is handily saved , enabling you to modify the pdf at a later time if required. When you use FormsPal, you can certainly complete documents without the need to be concerned about personal information breaches or data entries getting shared. Our secure platform ensures that your private details are maintained safely.

Form Tp 2 – Fill Out and Use This PDF

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