• Increase Text Icon
  • Decrease Text Icon
  • Email Icon
  • Print this page
You are here: Home . forms . form9numeric

Numeric Listing of Managed Care Quality Assurance Forms

Managed Care Quality Assurance Main Forms page

Numeric Listing of Managed Care Quality Assurance Forms
TDI Form Number Description File FormatLanguage
FIN306
Officers and Directors Page
Complete Listing of all Current Officers and Directors
PDF English
FIN536
HMO Physician/Provider Contract Checklist
Used as guide to indicate the mandatory provisions and benefits required in a Provider Contract
PDF English
FIN537
WC Network Application Form
Workers' Compensation Health Care Network Application
PDF English
FIN542
HMO Delegation Agreement Checklist
PDF English
FIN543
Preferred Provider Benefit Plan and Exclusive Provider Benefit Plan Annual Report Form & Access Plan Checklist
PDF English
FIN544
HMO Network Access Plan Requirements
PDF English
FIN550
WC Network Provider Contract Checklist
PDF English
FIN551
WC Network Insurance Carrier Contract Checklist
PDF English
FIN552
Workers' Compensation Network Access Plan Checklist
WC Network Access Plan Checklist
PDF English
FIN553
Workers' Compensation Health Care Network Management Contracts Checklist
PDF English
FIN582
CERTIFICATION OF INDEPENDENCE AND QUALIFICATIONS OF THE REVIEWER
PDF English
FIN583
Holder of Bonds or Notes Over $100,000
PDF English
FIN589
Addendum to Biographical Affidavit
PDF English
FIN591
IRO Notice of Decision Template - HC
PDF English
FIN592
IRO Notice of Decision Template - WC
PDF English
fin593
HMO/INSURER PROMPT PAY PENALTY REPORTING FORM
PDF English
FIN596
Provider Network Contracting Entity Registration and Exemption Form
PNCE Registration and Exemption Form
PDF English
FIN601
HEALTH MAINTEANCE ORGANIZATION ANNUAL NETWORK ADEQUACY REPORT & ACCESS PLAN CHECKLIST
PDF English
LHL005
URA Application Form
Application to apply for URA Certification, renew a URA Certification or update a URA Certification
PDF English
LHL006
IRO Application
Application to apply for IRO Certification, renew an IRO Certification or update an IRO Certification
PDF English
LHL009
Request for Review by an IRO
Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
PDF English
LHL009 Spanish
Request for Review by an IRO
[ En EspaƱol ] - Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
PDF Spanish
LHL234
Application Package - Web Enterable
WORD English
LHL234
Application Package
PDF English
LHL234a
Other Professional Degrees - Web Enterable
A
WORD English
LHL234a
Other Professional Degrees
A
PDF English
LHL234a
Other Professional Degrees - Web Enterable
A
RTF English
LHL234
Application Package - Web Enterable
RTF English
LHL234b
Other Post-Graduate Education - Web Enterable
B
PDF English
LHL234b
Other Post-Graduate Education
B
PDF English
LHL234b
Other Post-Graduate Education - Web Enterable
B
RTF English
LHL234c
Other Work History - Web Enterable
C
WORD English
LHL234c
Other Work History
C
PDF English
LHL234c
Other Work History - Web Enterable
C
RTF English
LHL234d
Other Current Hospital Affiliations - Web Enterable
D
WORD English
LHL234d
Other Current Hospital Affiliations
D
PDF English
LHL234d
Other Current Hospital Affiliations - Web Enterable
D
RTF English
LHL234e
Other Previous Hospital Affiliations - Web Enterable
E
WORD English
LHL234e
Other Previous Hospital Affiliations
E
PDF English
LHL234e
Other Previous Hospital Affiliations - Web Enterable
E
RTF English
LHL234f
Other Practice Locations - Web Enterable
F
WORD English
LHL234f
Other Practice Locations
F
PDF English
LHL234f
Other Practice Locations - Web Enterable
F
RTF English
LHL234g
Malpractice Claims History - Web Enterable
G
WORD English
LHL234g
Malpractice Claims History
G
PDF English
LHL234g
Malpractice Claims History - Web Enterable
G
RTF English
LHL658
Application for Approval of Exclusive Provider Benefit Plan (EPBP)
PDF English
NOFR001
Prior Authorization of Health Care Services
PDF English
NOFR002
Prior Authorization of Prescription Drugs
PDF English
SN002
Notice to HMO Enrollees
PDF English
SN003
Workers Comp Network Sample Contingency Plan
PDF English
SN004
Workers Comp Net Sample Employee Acknowledgment Form
PDF English
SN005
Workers Comp Net Employee Acknowledgment Form
PDF Spanish
SN006
Workers Comp Net Sample Employee Acknowledgment Form - Chinese
PDF Chinese
SN007
Workers Comp Net Sample Employee Acknowledgment Form
PDF Vietnamese
SN008
Workers Comp Network Sample QI Report
PDF English
SN009
Sample URA Adverse Determination Notice, Health
PDF English
SN010
Sample URA Adverse Determination Notice, Specialty Health
PDF English
SN011
Sample URA Adverse Determination Notice, Workers Comp Net
PDF English
SN012
Sample URA Adverse Determination Notice, Workers Comp Non-Network
PDF English
SN013
Contract List
PDF English
SN014
Delegated Entity Data Form
Sample format for use by HMOs and WC HCNs when submitting delegation agreements to the Texas Department of Insurance
PDF English

This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.


For more information, contact:

Contact Information and Other Helpful Links