Do you need help filling out a TP1 Form for your taxes? The process can often be overwhelming and it’s important to make sure that all the boxes are properly checked off, as any mistakes could cause headaches down the line. Don’t worry though – there is now an easier way! In this blog post, we will provide step by step instructions on how to fill out a TP1 Form with ease so you can maximize your refund without any stress or hassle. Read on to learn more!
| Question | Answer |
|---|---|
| Form Name | Tp 1 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Request for Initial Outpatient Therapy (TP1) tp1 medicaid form |
Request for Initial Outpatient Therapy (Form
Request For Initial Outpatient Therapy (Form
CCP - Texas Medicaid & Healthcare Partnership |
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Texas Medicaid & Healthcare Partnership |
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PO Box 200735 |
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CSHCN |
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Austin TX |
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PO Box 200855 |
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Austin TX |
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CCP FAX: |
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FAX: |
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Medicaid Number: |
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CSHCN Number: |
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Client Name: |
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Date of birth: / |
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Telephone: |
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Client Address: |
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Has the child received therapy in the last year from the public school system? □ Yes □ No |
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Date of Initial Evaluation |
PT |
OT |
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SLP |
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A copy of the initial evaluation must be attached |
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Date of onset:
Category of Therapy Being Requested
PT/OT for: |
□ Developmental anomalies |
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Date of surgery |
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□ Cast Removal |
Date Removed |
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□ Serial Casting |
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□ Acute Episode of Chronic Condition |
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□ New Condition |
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□ Specialty Clinic |
□ Home Program |
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□ ADL (activities of daily living) |
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□ Equipment Assessment |
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□ Equipment Training |
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Speech for: |
□ Craniofacial |
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□ Developmental Anomalies |
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□ New Condition |
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□ Post Cochlear Implant |
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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 |
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Service Date(s) |
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Frequency per week |
Frequency per month |
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From: |
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To: |
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□ PT |
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□ OT |
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□ SLP |
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Procedure code(s) for therapy services:
Specialist |
Name |
Signature |
Physician |
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PT Therapist |
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OT Therapist |
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SLP Therapist |
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Date Signed
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Provider Information
Name: |
Telephone: |
Fax: |
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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: |
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PAN# |
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Valid |
To |
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FORM |
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Effective Date_07302007/Revised Date_06012007 |