Form 1143, Cystic Fibrosis Treatment Agents Prior Authorization Request (CSHCN)

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Effective Date

2/2024

1143.pdf

Instructions

Updated: 2/2024

Purpose

HHSC requires prior authorization for cystic fibrosis treatment agents (PDF) for people enrolled in the Children with Special Health Care Needs (CSHCN) Services Program.

How to Submit

Providers should send the completed form by fax or mail to the CSHCN Services Program.

Fax: 512-776-7238

Mail:

Texas Health and Human Services
CSHCM Services Program
Mail Code 1938
P.O. Box 149030
Austin, TX 78714-9947

Questions

Refer comments or questions about this form to the CSHCN Services Program at 800-252-8023.