Healthcare Coverage Templates
Documents:
87
PDF 
Word
This document proves that an individual's previous insurance policy has ended.
This document is used for making adjustments to healthcare claims in the state of Virginia.
This Form is used for small businesses in California to apply for coverage through Covered California for Small Business.
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 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 documenting the first use of Medicaid benefits in the state of Washington. It is available in English and Cambodian languages.
This document is used for submitting reimbursement claims for healthcare expenses in Pennsylvania using the non-network direct reimbursement method.
This Form is used for facilities enrolling with Health First Colorado in Colorado to provide attestation of their services and eligibility.
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 provides information about health coverage options available to employees in the state of New Mexico. It outlines the various plans and benefits offered and explains how employees can enroll and access these benefits.
This Form is used for requesting prior authorization for out-of-state services in Oregon.
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 provides information about health coverage options available through employment in Alabama. It includes details about the types of coverage, eligibility requirements, and how to enroll.
This form is used for obtaining prior authorization for oxygen equipment in the state of Wisconsin.
This form is used for submitting a consolidated appeal request to the state of Tennessee in Somali language.
This form is used for requesting special authority for the medication Letermovir in the province of British Columbia, Canada.
This Form is used for notifying participation in World Trade Center rescue, recovery, or clean-up operations in New York City.
This form is used for renewing Medi-Cal coverage in California. It is available in Russian language.
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 submitting a prior authorization request for Cimzia medication in the state of Vermont.
This form is used for renewing your Medi-Cal benefits in California. It is available in the Lao language.
This Form is used for applying for Medicare in New Brunswick, Canada.
Form 3853 Health Coverage Exemptions and Individual Shared Responsibility Penalty - California, 2022
This Form is used for reporting health coverage exemptions and calculating the individual shared responsibility penalty in California.
This document updates the insurance information of Medicaid recipients in Louisiana.
