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Texas Department of Insurance
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HMO Forms and HMO Form Filings - Life, Accident, and Health

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TDI form number Description Format Language
HMO001 Consumer Choice Evidence of Coverage (EOC) Checklist - Individual Plans
 PDF English
HMO002 Consumer Choice Evidence of Coverage (EOC) Checklist - Large Employer and Conversion Plans
 PDF English
HMO003 Consumer Choice Evidence of Coverage (EOC) Checklist - Small Employer and Conversion Plans
 PDF English
HMO004 Evidence of Coverage (EOC) Checklist - Individual Plans
 PDF English
HMO005 Evidence of Coverage (EOC) Checklist - Large Employer and Conversion Plans
 PDF English
HMO006 Evidence of Coverage (EOC) Checklist - Small Employer and Conversion Plans
 PDF English
HMO007 Evidence of Coverage (EOC) Checklist - Single Health Care Service Plan - Dental Care
 PDF English
HMO008 Evidence of Coverage (EOC) Checklist - Single Health Care Service Plan - Vision Care
 PDF English
NOFR001 Prior Authorization of Health Care Services
 PDF English
NOFR002 Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
 PDF English

For more information, contact: LifeHealth@tdi.texas.gov