Healthcare Provider Templates
Documents:
459
PDF 
Word
This form is used for submitting a prior authorization request for the prescription drug Synagis in the state of Wisconsin.
This form is used for requesting prior authorization for a brand name medication in Vermont.
This document is used for making inquiries about medical providers in the state of Virginia.
This form is used for requesting a referral to a physician in Vermont.
This document allows individuals in Idaho to request a change in their primary physician.
This form is used for the NMDOH Perinatal Hepatitis B Program in New Mexico.
This document is an endorsement hospital agreement for pre-hospital emergency care in the state of Nevada. It outlines the terms and conditions between the hospital and pre-hospital care providers.
This Form is used for applying for the Ryan White Care program in the state of New Hampshire. The program provides HIV/AIDS-related medical care and support services to eligible individuals.
This Form is used for renewing the licensure of Ambulatory Surgical Treatment Centers in the state of Illinois.
This document is used for obtaining legally required consent from individuals in Alpine County, California. It ensures that individuals are fully informed and understand the risks and benefits associated with a particular activity or procedure.
This document is used for authorizing the release of medical information under the Health Insurance Portability and Accountability Act (HIPAA) in New York.
This Form is used for submitting a prior authorization request for Cimzia medication in the state of Vermont.
This form is used for requesting a urine drug test in the state of Vermont. It is specifically designed to document and request a urine sample for the purpose of screening for the presence of drugs.
This document is used for transferring care in Washington state. It is available in Urdu language.
This form is used for pharmacies in Washington to provide a statement of services rendered. It is available in Chinese Simplified language.
This document is for patients in New Hampshire who are applying for the Therapeutic Cannabis Program. It outlines the application process for obtaining medical cannabis.
This Form is used for ordering clinical materials through the BCCP program in the state of New Hampshire.
This type of document is used for transferring care in Washington state. It is available in Amharic language.
This questionnaire is used by healthcare providers in Delaware to respond to accommodation requests made under the Americans with Disabilities Act (ADA).
This Form is used for authorizing the release of personal information in the state of Maine. It allows individuals to grant permission for their information to be shared with specified individuals or organizations.
This form is used for notifying the state of Illinois about the use of ventilators in nursing facilities.
This Form is used for making medical treatment decisions in Illinois. It is available in both English and Spanish versions.
This form is used for submitting a request for Medicaid subrogation in the state of Louisiana.
This document provides contact information for ambulatory sites in New Jersey. Find the right contacts for your healthcare needs.
This form is used for applying to become a provider for the Iowa Medicaid Universal Home-And Community-Based (HCBS) Waiver program. It is necessary to complete this application in order to be considered for eligibility to provide services under the waiver program.
This document is used for the review of direct care observations conducted by clinicians for clients in North Dakota.
This form is used for making referrals to a diabetes prevention program in North Dakota. It helps individuals with prediabetes get the necessary support and resources to prevent or delay the onset of type 2 diabetes.
