Washington State Health Care Authority Forms

This Form is used for patients in Washington to affirm their oral health connections.

This document is a patient attestation form for oral health connections in Washington, specifically for individuals who speak Chinese Simplified. It is used to provide proof and agreement regarding oral health services.

This type of form is used for Negative Pressure Wound Therapy in the state of Washington.

This form is used for notifying the state of Washington about other provider preventable conditions (Oppc) by healthcare providers.

This Form is used for residents of Washington state to request out-of-state medical services that are not available locally.

This form is used for applying for the medication Perjeta (Pertuzumab) J9306 in the state of Washington.

This Form is used for submitting a Pharmacy Adjustment Request in the state of Washington. It is used to request adjustments or corrections to pharmacy claims.

This form is used for making a referral for Pediatric Palliative Care (PPC) in Washington. It also serves as a notification to the appropriate parties within 5 days of the referral being made.

This form is used for submitting a pharmacy statement in the state of Washington. It is used to provide information about prescription medications and related expenses.

This form is used for post-pregnancy screening in Washington.

This Form is used for requesting additional doses of Synagis due to weight increase for clients in Washington.

This Form is used for requesting prior authorization for removable prosthetic devices in the state of Washington.

This document is a request form for the medication called Synagis in the state of Washington.

This Form is used for the Residential Substance Use Treatment Provider Agreement in Washington.

This form is used for authorizing secure ambulance transportation to and from behavioral health services in Washington.

This Form is used for requesting authorization for vision care services in the state of Washington.

This form is used for requesting reimbursement for interim pharmacy and medical services provided to foster children in the state of Washington.

This form is used for requesting authorization for Voretigeme Neparvovec-Rzyl (Luxturna) in the state of Washington.

This form is used for requesting Washington Apple Health coverage for children in the Unaccompanied Refugee Minors (URM) program in Washington state.

This form is used for disclosing conflicts of interest for the Health Technology Clinical Committee in Washington state.

This Form is used for authorizing electronic transfer of funds in Washington.

This form is used for ensuring housing habitability standards in the state of Washington. It outlines the requirements and regulations that must be met to ensure safe and healthy living conditions for residents.

This Form is used for obtaining participation authorization and consent for information sharing for health home services in the state of Washington.

This Form is used for authorizing and sharing health information in Washington's Health Home Participation program for Cambodian residents.

This form is used for providing authorization and consent for participating in a health home program and sharing of information in Washington state.

This Form is used for authorizing participation in home healthcare and consent for information delivery in Washington.

This form is used for authorizing the release of orthodontic information in Washington.

This form is used for healthcare providers in Washington to participate in the Gemt network.

This form is used for releasing information related to substance use disorder services in Washington state. It allows individuals to authorize the sharing of their treatment records for substance abuse treatment purposes.

This type of document is used for releasing information regarding substance use disorder services in Washington for Somali individuals.

This type of document is a permit for the disclosure of information related to substance use disorder services in Washington. It is used to authorize the release of confidential information for the purpose of treatment and support.

This form is used for releasing information related to Substance Use Disorder (SUD) Services in Washington State. It is available in both English and Russian.

This document is a funding application form specifically designed for individuals and organizations from the Bipoc community in Washington seeking seed funding for their projects.

This Form is used for authorizing the release of information in the state of Washington.

This form is used for obtaining electronic service approval from the Board of Appeals in Washington.

This form is used for filing a petition to review an initial order in Washington state.

This form is used for filing a petition to request reconsideration of a final order in the state of Washington.