Texas Health Insurance Pool Claim, Change & Other Forms

Please note that documents in Adobe Reader (pdf format) require a recent version of the free software.
Use the following link  to download: Adobe Reader

Appeal Forms

• Grievance Procedure Form- Pharmacy (Medco Health Solutions/Express Scripts) 
  (for other prescription benefit forms, open the Pharmacy Program link)

 

• Grievance Procedure Form- (All Other Appeals)

 

Other Forms

• Financial Information Privacy Notice
• HIPAA Notice of Privacy Practices
• Standard Authorization Form to Disclose Protected Health Information (“PHI”)

Please note that documents in Adobe Reader (pdf format) require a recent version of the free software.
Use the following link  to download: Adobe Reader

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