Clinical Prior Authorization Forms

• Abortion Certification (10/13/10)
• Chiropractic Services Prior Authorization (10/13/10) 
• Durable Medical Equipment (DME) Ownership, Operation, and Maintenance Agreement  (10/19/10)
• Eyeglasses -Medical Necessity  (07/14/11)
• Hysterectomy Consent (10/13/10)
• J Code - General Prior Authorization - Unlisted J Code (03/11/11)
• J Code - Unclassified Drugs Prior Authorization - MEDICAL BENEFIT ONLY (11/14/11)
• Medical Necessity (10/13/10)
• Out-of-State Preadmission Request Form (10/13/10)
• Out-of-State Psychiatric Hospital Admission Notification Form (10/13/10)
• Out-of-State Urgent and Emergent Admission Notification Form (10/13/10)
• Pre-Procedure Request Form (10/13/10)
• Therapy Extension Form, PTOTST, Children (includes home health agencies and outpatient services) AND Adults (home health agencies only) (12/9/11)
• Therapy Extension Form, PTOTST, Adult  - (outpatient services only does not include home health agencies) (11/8/11)
• Urine Drug Test Prior Authorization (07/26/10) 

   

Dental Prior Authorization Forms

Fraud, Abuse & Team Care Referral Form (03/17/11)

Pharmacy Prior Authorization Request and Order Forms

Transportation Form - Medicaid Non-Emergency Medical Transport (9/22/2010)

Forms related to the following topics are located at Vermont Medicaid/Forms. (This link will take you away from the DVHA website.)

• Claims
• Electronic Data Interchange (EDI)/Trading Partner
• Enrollment
• Third Party Liability (TPL)