DSHS Community Health Services Forms

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Do you need to submit a form for your particular service? The forms home page has every form Family and Community Health staff and contractors will need. Just click on the service area you are interested in and the form you need should be listed below.

NEW - Revised Forms

Breast and Cervical

BCCS Data Collection Tools

Med-IT User Request Form


Medicaid for Breast and Cervical Cancer (MBCC) Information - formerly Treatment Act

In Texas, Medicaid for Breast and Cervical Cancer is a special Medicaid program that provides access to cancer treatment services for qualified women. This program was implemented to provide full Medicaid benefits to uninsured women under age 65 that meet eligibility requirements, and are in need of treatment for breast or cervical cancer. Click here to access MBCC information and forms

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Contractor Vouchers and Reporting

  • Form #B-13, State of Texas Purchase Voucher
    Purpose: To request monthly reimbursement using a State of Texas Purchase Voucher. For form B-13 and instructions go to http://www.dshs.state.tx.us/grants/forms.shtm
  • For program specific vouchers and instructions refer to the appropriate program section of this page.

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Epilepsy


Family Planning     

External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services.

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Primary Health Care

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Title V MCH Fee for Service

(File Format Viewing Information)
External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services.

 


Last updated August 25, 2014