Texas Medicaid: PSON form must be completed to avoid service delays

The Practitioner’s Statement of Need (PSON) form must be completed fully when requesting personal assistance services (PAS), personal care services (PCS) and habilitation for Texas Medicaid members. Services that require the PSON form include assistance with activities of daily living, such as preparing meals, laundry, bathing, dressing and grooming.

PSON form requirements

The PSON form must be completed by a physician, nurse practitioner (NP) or physician assistant (PA) who has examined the member and reviewed the member’s medical record within the last 12 months.

To be considered complete, the PSON form must include all of the following information:

• Member name, Medicaid number and date of birth
• ICD-10 diagnosis codes for the member’s active diagnosis(es)
• Declaration of physical, cognitive or behavioral limitations related to the member’s active diagnosis(es)
• Symptom or limitation related to the diagnosis(es), unless the declaration response is ‘no’
• Practitioner’s signature, printed name, date, Texas provider identifier (TPI) and license number

This form is time sensitive and if not returned within 10 business days, the member’s services will automatically be denied, which could cause delays in care.

Obtain and submit the PSON form

Download a PDF version of the form, or to request a fillable PSON form, contact the STAR Kids Service Coordinators at 877-352-7798. Once all sections of the PSON form are complete, fax the completed PSON form to 888-843-7061.

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