Texas Department of State Health Services
Children with Special Health Care Needs
(CSHCN) Services Program
Physician/Dentist Assessment Form
Formulario de Evaluación del Médico o Dentista
This form is part of the
application to the CSHCN
Services Program to be
completed by applicant's
physician or dentist.
Applicant Information
First name:
Date of birth:
Este formulario forma parte
de la Solicitud de
Prestaciones del Programa
de Servicios CSHCN a
cumplimentar por el medico
o dentista del solicitante.
CSHCN client number (if known):
The applicant meets one of the following definitions:
A person younger than 21 years of age who has a chronic physical or developmental
condition that:
• Will last or is expected to last for at least 12 months AND
• Results in, or if not treated, may result in limits to one or more major life
activities AND
• Requires health and related services of a type or amount beyond those
required by children generally AND
• Has a physical (body, bodily tissue, or organ) manifestation AND
• May exist with accompanying developmental, mental, behavioral, or emotional
conditions BUT is not solely a delay in intellectual development or solely
a mental, behavioral, or emotional condition.
Return the signed form to
the applicant or mail to
CSHCN Services Program
MC 1938
PO Box 149347
Austin, TX 78714-9347
If you have any
questions, call
1-800-252-8023.
A person of any age who has cystic fibrosis.
I certify that the applicant is medically eligible based on
the following diagnoses:
Codes must be at the
highest level of
specificity.
If filling out prior to 10/1/15,
use ICD-9 codes only.
Page 1 of 2
Last name:
Medical Information
Instructions:
If filling out on or after
10/1/15, use ICD-10 codes
only.
Middle name:
Yes
Primary ICD code:
Combination Code:
Primary ICD Code Description:
Combination Code Description:
Additional ICD code:
Combination Code:
Additional ICD Code Description:
Combination Code Description:
Additional ICD code:
Combination Code:
Additional ICD Code Description:
Combination Code Description:
CSHCN Services Program Physician/Dentist Assessment Form
No
Form T-4 Rev. 08-2015
Certification of Needs
Attach additional pages
Would an inability to get health care cause a permanent increase in
to this form, if necessary. disability, pain, suffering, or death?
Yes
No
If a lack of care will not cause permanent harm OR if the applicant is actively planning
to live in an institution, please include any information on complexity or severity of the
condition that the CSHCN Services Program should know.
Services, other than medical or dental, you think the applicant may require.
For planning purposes
only. Your answers will
not affect eligibility
decisions.
Case Management
Home Health
Mental Health
Was the applicant born before 36 weeks of gestation?
Yes
No
Has the applicant spent 14 consecutive days out of the hospital?
Yes
No
Is applicant's condition a result of a traumatic injury or accident?
Yes
No
Date of trauma or accident:
Date of discharge if hospitalized:
Physician/Dentist Information
First name:
Last name:
Specialty:
Phone number:
Physician address:
City:
State:
ZIP code:
NPI #:
Acknowledgement
I understand that by signing below I am stating from my personal
knowledge that the facts on this form are true and correct.
X
Signature
Page 2 of 2
CSHCN Services Program Physician/Dentist Assessment Form
Date (mm/dd/yy)
Form T-4 Rev. 08-2015