Healthcare Provider Templates

This document is a clinical practice inquiry specific to the state of New Hampshire. It likely contains information regarding healthcare practices, guidelines, or research relevant to medical professionals in the state.

This document is for the Program of All-inclusive Care of the Elderly (PACE) in New Mexico. It is a long-term care medical assessment.

This form is used for documenting the transfer of patients between healthcare facilities in North Dakota and recording any infection control measures taken during the transfer.

This document authorizes pharmacies in North Dakota to administer immunizations.

This document is used for obtaining medical statements from providers in Rhode Island.

This form is used for referring individuals to the Medicaid Health Home program in South Dakota.

This document outlines the self-insured employer's plan for managed care in South Dakota. It provides information on how employers can provide healthcare coverage to their employees through a managed care system.

This Form is used for requesting home care services in Rhode Island.

This document is used to certify the medical necessity of an external infusion pump in Rhode Island.

This document provides instructions for completing the Rhode Island Medicaid Prior Authorization Form. It is used to request approval for specific medical services or treatments before they can be covered by Medicaid in Rhode Island.

This Form is used for applying for a Narcotic Treatment Program for controlled substances in the state of South Carolina.

This Form is used for reporting cases of hepatitis in Oklahoma as per the requirements of the Oklahoma State Department of Health (OSDH).

This document is used to certify the Medicaid credit balance report in South Carolina.

This form is used for authorizing the release of medical information in South Dakota. It is required to give permission for healthcare providers to share your medical records with other individuals or organizations.

This Form is used for referring patients to care coordination services in Utah. It helps facilitate communication and collaboration among healthcare providers to ensure patients receive appropriate and timely care.

This form is used for a physician in Oklahoma to assert a lien against a patient's personal injury settlement proceeds.

This document for residents of South Carolina is used to justify the need for medical treatments or services. It is typically required by insurance companies to determine coverage eligibility.

This Form is used for filing complaints against facility administrators in South Dakota's Board of Nursing.

This document is a Medical Orders for Scope of Treatment form specific to the state of South Dakota. It is used for outlining an individual's preferences for medical treatment, including end-of-life decisions and resuscitation orders.

This document is used for obtaining prior authorization for the medication Valganciclovir Hydrochloride (Valcyte) in the state of Illinois.

This form is used for reporting the hospice utilization in Florida for the July-December period.

This Form is used for healthcare providers in Ohio to create a treatment plan for their patients.

This is a document that can be used when individuals would like to appeal a decision by their insurance company to deny authorization.

This is a document that individuals can use when they would like to appeal a decision about a medical necessity by their insurance company.

The purpose of this type of sample is to inform a patient that their doctor will no longer provide medical care for them.

Individuals may use a letter such as this as a reference when they would like to request a copy of their records from a medical organization where they have been treated.

This Form is used for requesting information from a healthcare provider in Arizona.

This document is a mandatory report form used in Connecticut to report impaired practitioners. It is used to ensure the safety and well-being of patients by addressing concerns related to the impairment of healthcare practitioners.

This document provides instructions for healthcare providers in Florida on how to complete the prenatal screen.

This quiz is designed to test your knowledge about medical errors in the state of Florida.

This form is used for applying for an adjustment to the scope-of-service rate for Federally Qualified Health Centers in Colorado. It also includes an attestation.

This form is used for obtaining prior authorization for pharmaceuticals that will be administered in an outpatient hospital setting in Colorado.

This form is used for reviewing and assessing the nutrition needs of individuals who require medical food in the state of Illinois.

This document is for obtaining prior authorization for the medication Selzentry (Maraviroc) in the state of Florida. It is used to request approval from the insurance company before starting treatment with this medication.