H1551 pdf download - think, that
Form H "Treatment Verification Form - Medicaid for Breast and Cervical Cancer" - Texas
Office Mailing Address and Telephone No.
After you pick a language, press 2.
Treatment Verification Form &#x; Medicaid for Breast and Cervical Cancer
Take this form to the doctor you are seeing for cancer treatment. The doctor will need to fill out the form.
After the doctor has filled out this form, mail it to the above address or fax it toll-free to If we don't get this form, we may delay
or end your Medicaid for Brest and Cervical Cancer benefits.
To be filled out by the person getting cancer treatment:
give my permission to release that facts asked for on this form.
To be filled out by doctor:
We need verification of the patient's medical needs to determine continued eligibility for services. After completing this form, please return it
to the patient or fax it toll-free to
is receiving "active treatment" for breast or cervical cancer, defined as medical treatment
following a cancer diagnosis that is intended to cure or otherwise treat a diagnosed cancer.
"Active treatment" may include some or all of the following; surgery, chemotherapy, radiotherapy, medication (e.g., ongoing hormonal
treatment for ER/PR (+) breast cancer), and active disease surveillance for triple negative receptor breast cancer. Reconstructive
surgery (e.g., breast or bladder reconstruction) is considered "active treatment" if it is intended to permanently correct a physical
condition resulting from either the diagnosed cancer or the treatment of the diagnosed cancer. Ongoing treatment of a persistent
condition resulting from a diagnosed cancer or treatment of a diagnosed cancer is not considered "active treatment" if cancer is no longer
present or in need of treatment.
is no longer receiving "active treatment" for breast or cervical cancer according to the
I certify under penalty of perjury that the information I have provided on this form is true and complete to the best of my knowledge.
Name of Doctor (Type or print)
Office Address (Street, City, State and ZIP Code)
Area Code and Telephone No.
Office Mailing Address and Telephone No.
After you pick a language, press 2.
Treatment Verification Form &#x; Medicaid for Breast and Cervical Cancer
Take this form to the doctor you are seeing for cancer treatment. The doctor will need to fill out the form.
After the doctor has filled out this form, mail it to the above address or fax it toll-free to If we don't get this form, we may delay
or end your Medicaid for Brest and Cervical Cancer benefits.
To be filled out by the person getting cancer treatment:
give my permission to release that facts asked for on this form.
To be filled out by doctor:
We need verification of the patient's medical needs to determine continued eligibility for services. After completing this form, please return it
to the patient or fax it toll-free to
is receiving "active treatment" for breast or cervical cancer, defined as medical treatment
following a cancer diagnosis that is intended to cure or otherwise treat a diagnosed cancer.
"Active treatment" may include some or all of the following; surgery, chemotherapy, radiotherapy, medication (e.g., ongoing hormonal
treatment for ER/PR (+) breast cancer), and active disease surveillance for triple negative receptor breast cancer. Reconstructive
surgery (e.g., breast or bladder reconstruction) is considered "active treatment" if it is intended to permanently correct a physical
condition resulting from either the diagnosed cancer or the treatment of the diagnosed cancer. Ongoing treatment of a persistent
condition resulting from a diagnosed cancer or treatment of a diagnosed cancer is not considered "active treatment" if cancer is no longer
present or in need of treatment.
is no longer receiving "active treatment" for breast or cervical cancer according to the
I certify under penalty of perjury that the information I have provided on this form is true and complete to the best of my knowledge.
Name of Doctor (Type or print)
Office Address (Street, City, State and ZIP Code)
Area Code and Telephone No.
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