Washington State Health Care Authority Forms

This form is used for applying for the Washington State Recovery Residence Operating Loan Revolving Fund. It is for recovery residences in Washington State that are in need of financial assistance.

This form is used for registering as a submitter for drug price transparency in the state of Washington.

This form is used for the Public Employees Benefits Board (PEBB) Program in Washington state. It is a Medical History Statement (Evidence of Insurability) form that individuals need to fill out as part of their enrollment process.

This document is used for an agreement between an individual provider and a healthcare organization in Washington state. It outlines the terms and responsibilities for the provider who does not bill for their services.

This document is used for establishing a contractual agreement between an organization and a nonbilling provider in the state of Washington.

This form is used for updating the Acute Physical Medicine and Rehabilitation (PM&R) information in Washington state.

This form is used for requesting admission or extension of acute physical medicine and rehab services in Washington.

This form is used for declaring the loss, theft, or destruction of a warrant in the state of Washington.

This form is used to sign an agreement to pay for healthcare services in Washington.

This Form is used for healthcare providers in Washington to submit an attestation for participating in the Apple Health 340b program.

This form is used for attesting to the Collaborative Care Model (CoCM) in Washington. It is used to provide documentation and certification of the implementation of CoCM for healthcare professionals.

This form is used for requesting bathroom equipment in the state of Washington.

This Form is used for authorizing bathroom equipment in Washington. It is available in Chinese Simplified language.

This Form is used for requesting bathroom equipment in Washington for individuals who speak Lao.

This form is used for requesting bathroom equipment in Washington. It is specifically translated into Korean.

This Form is used for requesting bathroom equipment in Washington for individuals who speak Cambodian.

This form is used for requesting bed and pillow encasements in Washington.

This form is used for requesting bathroom equipment in Washington, specifically for Somali speakers.

This form is used for requesting bathroom equipment in Washington, but it is in Russian.

This Form is used for requesting compression garments in the state of Washington. It is used to provide support and pressure to specific areas of the body for medical or therapeutic purposes.

This Form is used for obtaining compression garments in Washington for Korean residents.

This form is used for authorizing the use of compression garments in Washington.

This form is used to obtain authorization for compression garments in Washington for Somali speakers.

This document is used for obtaining consent to coordinate care and treatment in the state of Washington.

This Form is used for obtaining prior authorization for corneal cross-linking in the state of Washington.

This Form is used for the Core Provider Agreement in Washington state.

This document for the Denture Agreement of Acceptance in Washington. It is used for dental patients who are accepting dentures and outlines the terms and conditions of the agreement.

This form is used for accepting and agreeing to the terms of a denture agreement in Washington. It is available in Amharic language.

This form is used for accepting a denture agreement in Washington. It is available in Somali language.

This form is used for individuals in Washington who have been diagnosed with diabetes and need to request an extension on their limitations for medical coverage.

This form is used for requesting stage 2 bariatric surgery in Washington.

This form is used for requesting authorization for the medication Elapegademase-Lvlr (Revcovi) in the state of Washington.

This Form is used for requesting an exception to the rule for a Tens Unit and its accessories in the state of Washington.

This Form is used for submitting a request for Exondys 51 (Eteplirsen) medication in Washington.