Applied Behavior Analysis
- ABA Medical Prior Authorization Form (12/16/2021)
Behavioral 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 (07/01/2022) - TYPE IN
- VT Medicaid Request for Per Diem Rate for Mental Health Extended Stays in Emergency Departments (07/01/2022) - WRITE IN
Chiropractic
- Chiropractic Services Prior Authorization (07/29/2022)
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 (09/23/2021)
- Augmentative Communication Device (11/12/2020)
- Durable Medical Equipment (DME) Ownership, Operation, and Maintenance Agreement (11/18/2021)
- Eyeglasses -Medical Necessity (05/18/2020)
- Foot Orthotic Tool, custom (08/30/2022)
- Medical Necessity, General (example - orthotics, prosthetics, medical supplies, and durable medical equipment) (11/04/2021)
- Non-Invasive Airway Assistance Devices (CPAP,BiPAP,AutoPAP) (08/31/2022)
- Orthotic Tool - (See Foot Orthotic Tool, custom)
- Shower Chair Form (09/03/2021)
- TENS Evaluation Tool (12/27/2021)
-
Wheelchair Criteria - Complete Packet (02/05/2020)
- Vendor and Therapist Acknowledgement (02/11/2022)
- Wheelchair Form : Positioning Evaluation and Prescription Form (02/11/2022)
- Wheelchair: Basic AND Rental: Evaluation and Prescription Form (10/06/2021)
Laboratory and Radiology
- Genetic Testing Prior Authorization (08/05/2020)
- Urine Drug Test Prior Authorization (07/26/2010)
Out-of-Network
-
Out-of-Network Elective Office Visit Request (10/16/2020)
- Out-of-Network Preadmission Request Form (10/16/2020)
- Out-of-Network Urgent and Emergent Admission Notification Form (10/16/2020)
Pharmacy
Procedures
- Abortion Certification 219A (06/11/2014)
- Abortion Certification 219B (06/11/2014)
- Hysterectomy Consent (05/05/2015)
- Pre-Procedure Request Form (09/22/2020
- Sleep Study Form (10/06/21)
- Sterilization Consent Form (02/19/2018)
Therapy
-
Therapy Extension Form, PTOTST, Pediatric Services (does not include home health agencies) (10/19/2020)
- Therapy Extension Form, PTOTST, Adult Services (does not include home health agencies) (10/19/2020)
- Therapy Extension Form, PTOTST, Adult and Pediatric Services (home health services only) (10/19/2020)
- Cover Sheet, PTOTST (10/19/2020)
Uniform Medical, Mental Health and Behavioral Health Prior Authorization Form
- Uniform Medical Prior Authorization Form (12/2016)