Form Tp 2 PDF Details

Form Tp-2 is a form that is used by the Internal Revenue Service to determine if an individual or organization has engaged in a prohibited tax shelter transaction. A prohibited tax shelter transaction is defined as any transaction or scheme that has the effect of reducing, avoiding, or deferring tax liability. Form Tp-2 must be filed by the taxpayer or organization who engaged in the transaction, and must be accompanied by a statement explaining why the transaction qualifies as a prohibited tax shelter transaction. Penalties may be assessed for failure to file Form Tp-2, so it is important to understand what constitutes a prohibited tax shelter transaction and how to file this form accurately.

QuestionAnswer
Form NameForm Tp 2
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesCochlear, TX, TPI, ADL

Form Preview Example

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

From:

 

 

To:

 

 

 

 

 

 

 

PT

/

/

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OT

/

/

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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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.

Tips on how to fill out CCP portion 1

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.

Part no. 2 of filling in CCP

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!

Stage # 5 of filling in CCP

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.