HMO forms and templates - Managed Care Quality Assurance
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| TDI form number | Description | Format | Language |
|---|---|---|---|
| LHL718 |
Health Maintenance Organization (HMO) Physician / Provider Contract Requirements Used as guide to indicate the mandatory provisions and benefits required in a Provider Contract |
English | |
| SN019 |
HMO Major Medical Access Plan Template |
EXCEL | English |
| SN020 |
HMO Attempt to Contract Template |
EXCEL | English |
| SN021 |
HMO Dental Access Plan Template |
EXCEL | English |
| SN022 |
HMO Provider List Template |
EXCEL | English |
| SN023 |
HMO Vision Access Plan Template |
EXCEL | English |
| SN024 |
HMO Vision Provider List Template |
EXCEL | English |
For more information, contact: MCQA@tdi.texas.gov