- To request EPSDT coverage (for Medical, Dental, Mental Health, and Behavioral Health) for members under age 21, a Medicaid enrolled provider should submit a prior authorization request. Prior authorization forms can be found below.
- To request EPSDT coverage for Drugs use General Prior Authorization Form for most requests. Prior authorizations forms can be found at Pharmacy Prior Authorization Request Forms and Order Forms | Department of Vermont Health Access
- For more information:
- Section of the Vermont Medicaid General Billing and Forms Manual
- Health Care Administrative Rules: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services
- EPSDT services definition
Prior Authorization (PA) Requirements for Out-of-State Providers
- PA Requirements for Out-of-State Providers (01/01/2023) - Requirements for ALL Medicaid members (including ACO-attributed members)
Applied Behavior Analysis
- ABA Medical Prior Authorization Form (12/16/2021)
Mental Health
- VT Medicaid Admission Notification Form for Inpatient Psychiatric & Detoxification Services for In & Out of State Providers (01/01/2022) - TYPE IN
- VT Medicaid Admission Notification Form for Inpatient Psychiatric & Detoxification Services for In & Out of State Providers (01/01/2022) - WRITE IN
- VT Medicaid Child/Adolescent Inpatient Admission Notification - TYPE IN To be provided by the Designated Agency/SSA conducting the screening(01/31/2020)
- VT Medicaid Request for Per Diem Rate for Mental Health Extended Stays in Emergency Departments (01/01/2023) - TYPE IN
- VT Medicaid Request for Per Diem Rate for Mental Health Extended Stays in Emergency Departments (01/01/2023) - WRITE IN
- Request for Reconsideration: For Mental Health and Applied Behavior Analysis Services (10/01/2023)
Chiropractic
- Chiropractic Services Prior Authorization (11/22/2023)
Durable Medical Equipment
Please use the Medical Necessity, General form found below when there isn’t a specific form for requested service or equipment.
- Airway Clearance (12/05/2022)
- Adaptive Positioning Device (08/30/2024)
- Augmentative Communication Device (02/22/2024)
- Bathing and Toileting Device Form (02/22/2024)
- Compression Garments Order Form (02/22/2024)
- Durable Medical Equipment (DME):
- Ownership, Operation, and Maintenance Agreement (07/03/2024)
- Recycled DME Ownership, Operation, and Maintenance Agreement (03/19/2024)
- Eyeglasses -Medical Necessity (04/11/2023)
- Foot Orthotic Tool, custom (11/1/2023)
- Hospital Bed Form (09/04/2024)
- Medical Necessity, General (orthotics, prosthetics, medical supplies, and durable medical equipment) (04/11/2023)
***The Medical Necessity, General Form will no longer be required starting 3/1/2025. Please see the January 24, 2025, Banner page for more information. This form will be removed on 4/1/2025.*** - Orthotic Tool - (See Foot Orthotic Tool, custom)
- Stander Form (06/18/2024)
- Transcutaneous Electrical Nerve Stimulation (TENS) Evaluation Tool (08/30/2024)
- Wheelchair: Basic AND Rental: Evaluation and Prescription Form (06/18/2024)
- Wheelchair Form: Positioning Evaluation and Prescription Form (06/18/2024)
- Wheelchair Signature Acknowledgement Sheet (07/24/2024)
Gene Therapy Authorization Guide
- Gene Therapy Authorization Guide (02/22/2024)
Laboratory and Radiology
- Genetic Testing Prior Authorization (02/26/2024)
- Urine Drug Test Prior Authorization (07/26/2010)
Out-of-Network
- Out-of-Network Elective Office Visit Request Form (2/24/2025)
- Out-of-Network Preadmission Request Form (11/1/2023)
- Out-of-Network Urgent and Emergent Admission Notification Form (02/22/2024)
- See pre-procedure form below
Pharmacy
Procedures
- Abortion Certification 219A (06/11/2014)
- Abortion Certification 219B (06/11/2014)
- Hysterectomy Consent (05/05/2015)
- Pre-Procedure Request Form (02/10/2023)
- Sterilization Consent Form (09/01/2022)