Healthcare Services Templates

This document provides instructions for completing Form FA-24A which is used for coordinating hospice services and waiver or personal care services (PCS) in Nevada.

This form is used for referring elderly and disabled individuals to the Medicaid for the Elderly and People with Disabilities program in Texas. The form acts as a cover sheet for the referral process.

This document provides projections for national health expenditure in the United States from 2012 to 2022. It shows predicted trends and estimates for healthcare spending over the next decade.

This document is used for the identification and screening of individuals in New Mexico who may require Level I services under the PASRR program.

This document provides information about the privacy practices regarding client medical information in Washington. It is available in English and Mongolian.

Individuals who reside in British Colombia may use this form when they would like to apply to enter the Medical Service Plan (MSP).

This document is used for pregnant women to apply for assistance in Alaska.

This document is used to enroll as a healthcare provider in Arizona if you are located out-of-state.

This form is used for documenting the findings related to Form H1852 in the state of Texas.

This form is used for applying for the Teleplan service in British Columbia, Canada.

This document is used for making adjustments to healthcare claims in the state of Virginia.

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 applying for Medicaid under the Women's Way program in North Dakota. It is specifically designed for women who are seeking healthcare services related to breast or cervical cancer.

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

This document is an application form for the Children's Hearing Aid Program (CHAP) in Utah. It is used by participants to apply for hearing aids for children.

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 document is for understanding Medicare coverage outside of the United States. It provides information on what medical services are covered and the limitations of coverage when traveling or living abroad.

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

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 filing complaints related to emergency medical systems in the state of New Mexico.

This Form is used for facilities enrolling with Health First Colorado in Colorado to provide attestation of their services and eligibility.

This type of document provides counseling services for individuals in Iowa who have been exposed to a potential risk of HIV or other sexually transmitted infections.

This form is used for healthcare providers in Maryland to enter into an agreement with the state's Medical Assistance program.

This document is for those seeking a referral for home care services in Prince Edward Island, Canada. It provides information and assistance in finding reliable and professional home care providers in the area.

This Form is used for applying to the Catastrophic Drug Program in Prince Edward Island, Canada. This program provides financial assistance to residents who require high-cost medications.

This document is used to determine the level of care required for individuals in Pennsylvania. It helps in evaluating the appropriate level of medical or long-term care services needed for an individual.

This document is used for attesting the recovery from a health condition in the state of Washington.

This document is a checklist for the Certificate of Public Advantage (COPA) application in the state of Texas. It outlines the required documents and steps needed to apply for a COPA.

This Form is used for determining the selection of Community Living Assistance and Support Services (Class) in the Waco/Temple catchment area in Texas.

This Form is used for submitting a grievance related to the Personal Care Services Program in West Virginia.

This Form is used for prior authorization of vision services in Wisconsin.