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HMO Forms and HMO Form Filings - Life, Accident, and Health

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TDI Form Number Description File 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
LAHR344 HMO Reconciliation of Benefits to Schedule of Charges
 PDF English
LHL610 Consumer Choice Health Benefit Plans Data Certification
 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