Form 2605 "Member Sk-Sai Mdcp Review Signature" - Texas

What Is Form 2605?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 2605 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 2605 "Member Sk-Sai Mdcp Review Signature" - Texas

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Form 2605
December 2020
Member SK-SAI MDCP Review Signature
1. Member or Applicant Name (Last, First, Middle Initial) 2. Member Medicaid No. or Social Security No.
3. Date of Birth
4. Name of Legally Authorized Representative (LAR) [Last, First, Middle Initial]
5. LAR Relationship to Member
6. Date of Assessment
7. I have reviewed the information captured in the STAR Kids Screening and Assessment Instrument (SK-SAI).
Yes
No
8a. If the assessment results in a pending denial status, would you like to request a peer-to-peer conversation between the managed care
organization and your treating physician’s office?
Yes
No
8b. If yes, which treating physician of your choice would you like to be contacted to hold the peer-to-peer discussion?
Name (Last, First, Middle Initial)
Specialty (if the doctor is not your primary care physician (PCP)
Address
Area Code and Telephone No.
9. Additional Feedback from Applicant/Member/LAR
10. Additional Feedback from Nurse Assessor
Form 2605
December 2020
Member SK-SAI MDCP Review Signature
1. Member or Applicant Name (Last, First, Middle Initial) 2. Member Medicaid No. or Social Security No.
3. Date of Birth
4. Name of Legally Authorized Representative (LAR) [Last, First, Middle Initial]
5. LAR Relationship to Member
6. Date of Assessment
7. I have reviewed the information captured in the STAR Kids Screening and Assessment Instrument (SK-SAI).
Yes
No
8a. If the assessment results in a pending denial status, would you like to request a peer-to-peer conversation between the managed care
organization and your treating physician’s office?
Yes
No
8b. If yes, which treating physician of your choice would you like to be contacted to hold the peer-to-peer discussion?
Name (Last, First, Middle Initial)
Specialty (if the doctor is not your primary care physician (PCP)
Address
Area Code and Telephone No.
9. Additional Feedback from Applicant/Member/LAR
10. Additional Feedback from Nurse Assessor
Form 2605
Page 2 / 12-2020
11. How does the applicant/member/LAR want to receive a copy of the completed SK-SAI in addition to the copy that will be posted in the
Member Portal?
Provide mailing address:
Printed hard copy sent through mail.
Provide email address:
Electronic copy sent through email.
Does not want an additional copy.
12. Signatures
Check box if the applicant/member/LAR refuses to sign.
Signature of Applicant/Member/LAR
Printed Name of Applicant/Member/LAR
Date
Signature of Nurse Assessor
Printed Name of Nurse Assessor
Date
Managed Care Organization
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