Healthcare Provider Templates

This form is used for creating an advance care plan in Arkansas. It helps individuals outline their medical and end-of-life preferences, ensuring their wishes are respected if they become unable to communicate them.

This form is used for facility requirements in California. It provides information and guidelines on the necessary requirements for facilities in the state.

This form is used for obtaining a medical certificate for a child in Hawaii.

This Form is used for requesting prior authorization for long-term acute care in Nevada.

This form is used for requesting the release of medical records in the state of Hawaii.

This document provides a sample general letter for Illinois parents/guardians regarding measles.

This form is used for reporting serious adverse drug reactions that occur in hospitals in Canada.

This Form is used for tracking tetanus cases in New Jersey. It is a surveillance worksheet that provides instructions for reporting and documenting information related to tetanus cases.

This document is a survey conducted by health insurance carriers in Delaware. It gathers information about the health insurance needs and preferences of individuals in the state.

This document is used for Point of Service (POS) in Illinois. It pertains to a healthcare plan that allows participants to choose their own doctors and specialists.

This form is used for requesting prior authorization for high dose opioid drugs in the state of Minnesota.

This form is used for authorizing the provision of personal care services in North Dakota.

This document is for licensed associate professional counselors in North Dakota who wish to enroll as Medicaid providers. It includes an attestation form that confirms their eligibility and qualifications for providing counseling services under Medicaid.

This form is used in Washington for managing the side effects of hepatitis C treatment. It provides information on how to address and cope with the various side effects that may arise during the course of treatment.

This Form is used for applying for Medicaid enrollment in the state of Montana. It is used by individuals who meet the eligibility requirements and wish to receive healthcare coverage through the Medicaid program.

This document is an application for individuals or organizations to act as a discount medical plan in the state of Louisiana.

This Form is used for requesting authorization for Makena medication under Fee for Service Medicaid in Texas.

This form is used for authorizing the disclosure of protected health information in Texas.

This form is used for maintaining continuity of care for patients in Texas. It helps healthcare providers ensure that the necessary medical information is shared between different healthcare settings and professionals, promoting seamless and coordinated care.

This form is used for obtaining authorization to conduct a pre-enrollment assessment for managed care in the state of Texas.

This document is used to request an appeal for a provider enrollment denial in California. It allows providers to challenge the decision and provide additional information or documentation to support their case.

This form is used for summarizing information about patients with Acute Flaccid Myelitis (AFM).

This type of template is prepared to arrange a transfer of an individual from one doctor to another.

This is a notification completed by the employee and submitted to their employer after an FMLA leave - a leave requested and provided under the provisions of the Family and Medical Leave Act - is over.