Clinical Forms and Prior Authorization Forms

Abortion Certification 219A (06/11/2014)

Abortion Certification 219B (06/11/2014)

Airway Clearance - WRITE IN / TYPE IN (8/5/20)

Augmentative Communication Device - TYPE IN (11/12/20)

Chiropractic Services Prior Authorization - WRITE IN (10/19/2020)

Chiropractic Services Prior Authorization - TYPE IN (10/19/20)

Durable Medical Equipment (DME) Ownership, Operation, and Maintenance Agreement (06/09/20)

Eyeglasses -Medical Necessity (05/18/20)

Genetic Testing Prior AuthorizationWRITE IN / TYPE IN (08/05/20)

Hysterectomy Consent (05/05/15)

VT Medicaid Admission Notification Form for Inpatient Psychiatric & Detoxification Services for In & Out of State Providers (2019) - TYPE IN

VT Medicaid Admission Notification Form for Inpatient Psychiatric & Detoxification Services for In & Out of State Providers (2019) - WRITE IN

VT Medicaid Child/Adolescent Inpatient Admission NotificationTYPE IN (02/05/2020)

Medical Necessity: Requests for Orthotics, Prosthetics, Medical Supplies and Equipment - TYPE IN (10/24/19)

Medical Necessity: Requests for Orthotics, Prosthetics, Medical Supplies and Equipment - WRITE IN (10/24/19)

Non-Invasive Airway Assistance Devices (CPAP,BiPAP,AutoPAP) - WRITE IN (04/27/20)

Non-Invasive Airway Assistance Devices (CPAP,BiPAP,AutoPAP) - TYPE IN  (04/27/20)

Orthotic Tool - TYPE IN (10/28/20)

Out-of-Network Elective Office Visit Request - WRITE IN / TYPE IN (10/16/2020)

Out-of-Network Preadmission Request Form - WRITE IN / TYPE IN (10/16/2020)

Out-of-Network Urgent and Emergent Admission Notification Form - WRITE IN / TYPE IN (10/16/2020)

Pre-Procedure Request Form - WRITE IN / TYPE IN (09/22/20)

Service Authorization Form High Dollar Claims - WRITE IN / TYPE IN (8/3/20)

Shower chair / commode device (01/28/20)

Sleep Study Form - WRITE IN / TYPE IN (01/28/20)

Sterilization Consent Form (02/19/18)

TENS Evaluation Tool - WRITE IN / TYPE IN (11/16/20)

Therapy Extension Form, PTOTST, Pediatric Services (does not include home health agencies) - WRITE IN (10/19/20)

Therapy Extension Form, PTOTST, Pediatric Services (does not include home health agencies) - TYPE IN (10/19/20)

Therapy Extension Form, PTOTST, Adult Services- (does not include home health agencies) - WRITE IN (10/19/20)

Therapy Extension Form, PTOTST, Adult Services- (does not include home health agencies) - TYPE IN (10/19/20)

Therapy Extension Form, PTOTST, Adult and Pediatric Services (home health services only) - WRITE IN (10/19/20)

Therapy Extension Form, PTOTST, Adult and Pediatric Services (home health services only) - TYPE IN (10/19/20)

Cover Sheet, PTOTST - WRITE IN (10/19/20)

Cover Sheet, PTOTST - TYPE IN (10/19/20)

Uniform Medical Prior Authorization Form (12/16)

Urine Drug Test Prior Authorization (07/26/10)

Wheelchair Criteria - Complete Packet (02/05/20)

Wheelchair: Basic AND Rental: Evaluation and Prescription Form (07/01/19)

Wheelchair: Basic AND Rental: Evaluation and Prescription Form - TYPE IN (07/01/19)

J CODE Forms: Pharmacy Prior Authorization Request Forms and Order Forms 

Department of Vermont Health Access

280 State Drive
Waterbury, Vermont 05671-1010
Phone: 802-879-5900
Fax: 802-241-0260

Department Contact List for customer service, program telephone and fax numbers, and staff email

Hours of Operation: Monday-Friday (Excluding Holidays) 7:45am - 4:30pm

Public Record Requests
Kelly Provost
DVHA Public Records Officer
AHS.DVHALegal@Vermont.gov
Visit the Agency of Administration site for the Public Records Database

Report Medicaid Fraud, Waste, and Abuse