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Form 8484 Texas: What You Should Know

Patient's Personal Statement A completed document that describes the patient's current psychiatric issues and any medication(s) as well as any other medical histories. • Patient's Medical History The following documents must be provided if the client is being considered for Medicaid/Medicare and/or private insurance, and for any supplemental health insurance the client may be on. (See Medicare Schedule 1: Health Insurance) • Medical Records • Financial Aid This is a must. All financial aid documents should be completed and submitted. Health Insurance and Supplemental Insurance The following documents need to be submitted before a client is added to Medicaid or Medicare: • Medicaid Supplemental Policy Forms • • Medicaid Supplemental Policy Form A copy of the client's Medicaid/Medicare application receipt and/or Medicaid/Medicare authorization form (the one you signed that allowed the client to apply online) plus a copy of the Client's Social Security number. Additional Documentation • A written statement from the counselor(s), or other mental health professional(s) providing counseling for the patient regarding the effects of current mood or behavioral state(s) on the physical and mental health (including drug abuse/dependence, depression/anxiety, chronic pain, and bipolar disorder). • A written statement from a licensed psychiatrist/psychiatrist/psychologist or another mental health professional(s) providing counseling for the patient regarding the effects of current mood or behavioral state(s) on the physical and mental health (including drug abuse/dependence, depression/anxiety, chronic pain, and bipolar disorder). No doctor/client statement. Documentaries Documentary requirements These documents should be provided with each client and are a mandatory part of all cases being handled by a mental health professional. The following are examples of documentation that is required with each case.

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