Health Care Form Templates

This document is a form used by California managed care members to file a grievance about their healthcare services.

Health Care Consultant Agreement Template - Massachusetts

This document outlines the terms and conditions for a consulting agreement in the field of health care in the state of Massachusetts. It provides a template for healthcare professionals and consultants to establish their working relationship.

This form is used for submitting medical claims to Harvard Pilgrim Health Care.

This document is used for designating a person to make medical decisions on your behalf in the event that you are unable to do so. It is specific to the state of New York.

This document is used for appointing someone to make healthcare decisions on your behalf in New Jersey, and also includes your preferences for end-of-life care.

This document is used for granting someone the authority to make health care decisions on your behalf. It is specifically used at Poudre Valley Hospital in the City of Fort Collins, Colorado.

This document is used for renewing the license of a health care institution in the state of Arizona.

This document provides a checklist template to help you track your medication schedule.

This certificate template is used to recognize and thank individuals or organizations for their efforts in raising awareness about childhood cancer.

This Form is used for filing a potential liability claim under the CHAMPVA program.

This Form is used for granting someone else the power to make legal decisions on your behalf in the state of Oregon.

This Form is used for creating an Advance Directive for Health Care in the state of Virginia. It allows individuals to make decisions about their medical treatment in the event they become unable to communicate their wishes.

This document provides a comprehensive advance directive for healthcare in Virginia, with specific provisions for mental health conditions. It allows individuals to outline their healthcare preferences and designate a trusted person to make decisions on their behalf, taking into account their mental health needs.

This document is used to record vaccination information for individuals applying for immigration to the United States.

This document for creating a personal medication list to track your medicines.

This document is used to appoint a person to make health care decisions on your behalf if you are unable to do so. It is an important part of advance care planning.

This type of document, called a Health Care Proxy Form, is used in New York to appoint a person to make medical decisions on your behalf if you are unable to do so.

This form is used for expressing your wishes regarding healthcare decisions in Minnesota, in accordance with the Honoring Choices program.

This Form is used for applying for temporary involuntary hospitalization in Massachusetts.

This Form is used for creating an Education Affiliation Agreement between the Department of Veterans Affairs (VA) and a Non-VA Health Care Facility or Agency.

This form is used for notifying an applicant provider of their ineligibility for the In-home Supportive Services Program due to tier I crimes such as elder or dependent adult abuse, child abuse, or fraud against a government healthcare or supportive services program. The form is specific to the state of California.

This document is used for keeping records of progress notes related to attendant care in Arizona.

This Form is used for applicants to provide additional information in their own language (Farsi) for Medi-Cal application in California.

This form is used for reporting public health nursing activities. It is used to document various nursing activities and provide a record of services provided.

This document is a sample of the New York Statutory Short Form Power of Attorney. It is used for giving someone else the legal authority to act on your behalf in various financial and legal matters.

This form is a Power of Attorney (POA) form used by the Department of Veterans Affairs (VA). This form is used to designate a health care representative that will be able to act on behalf of the person in case they will no longer be able to make decisions themselves.

This form is used for submitting a letter of medical necessity to the Federal Flexible Spending Account Program (FSAFEDS). It is required to provide supporting documentation for reimbursement of eligible medical expenses.

This form is used for conducting a Staying Healthy Assessment for adults in California, specifically for Arabic-speaking individuals. It may include questions about health conditions, lifestyle habits, and preventive care.

This document is a form used in California to assess the health status of infants aged 0-6 months. It is available in the Russian language.

This document is for verifying personal exemptions related to health care reform policy in Minnesota.

This form is used for recording and documenting medical information and includes an anatomical figure for visual reference.

This Form is used for establishing a Power of Attorney in the state of Minnesota. It allows an individual to appoint someone to make important decisions on their behalf.

This form is used for monthly estimate of severance and business privilege taxes for providers of health care items and services in West Virginia.

This Form is used for entering into a contract for the Selected Reserve Special Pay Program. The program provides special pay for Selected Reserve Health Care Professionals in critically-short wartime specialties.

This Form is used for notifying the Office of Personnel Management (OPM) about any changes in your health benefits enrollment under the Federal Employees Health Benefits Program.

This form is used for reporting the results of the fire safety survey conducted in ambulatory health care facilities. It follows the guidelines set by the 2012 Life Safety Code.