Home Telemonitoring Services Prior Authorization Request Form
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Texas Medicaid
Prior Authorization Request Submitter Certification Statement
I certify and affirm that I am either the Provider, or have been specifically authorized by the Provider (hereinafter
"Prior Authorization Request Submitter") to submit this prior authorization request.
The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that they are
personally acquainted with the information supplied on the prior authorization form and any attachments or
accompanying information and that it constitutes true, correct, complete and accurate information; does not
contain any misrepresentations; and does not fail to include any information that might be deemed relevant or
pertinent to the decision on which a prior authorization for payment would be made.
The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that the
information supplied on the prior authorization form and any attachments or accompanying information was
made by a person with knowledge of the act, event, condition, opinion, or diagnosis recorded; is kept in the
ordinary course of business of the Provider; is the original or an exact duplicate of the original; and is maintained
in the individual patient's medical record in accordance with the Texas Medicaid Provider Procedures Manual
(TMPPM).
The Provider and Prior Authorization Request Submitter certify and affirm that they understand and agree that
prior authorization is a condition of reimbursement and is not a guarantee of payment.
The Provider and Prior Authorization Request Submitter understand that payment of claims related to this prior
authorization will be from Federal and State funds, and that any false claims, statements or documents,
concealment of a material fact, or omitting relevant or pertinent information may constitute fraud and may be
prosecuted under applicable federal and/or State laws. The Provider and Prior Authorization Request Submitter
understand and agree that failure to provide true and accurate information, omit information, or provide notice
of changes to the information previously provided may result in termination of the provider’s Medicaid
enrollment and/or personal exclusion from Texas Medicaid.
The Provider and Prior Authorization Request Submitter certify, affirm and agree that by checking "We Agree"
that they have read and understand the Prior Authorization Agreement requirements as stated in the relevant
Texas Medicaid Provider Procedures Manual and they agree and consent to the Certification above and to the
Texas Medicaid & Healthcare Partnership (TMHP) Terms and Conditions.
□
We Agree
F00032
Page 1 of 2
Revised Date: 02/01/2016 | Effective Date: 04/01/2016
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