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)
Foot Orthotic Tool, custom - WRITE IN/ TYPE IN (03/26/21)
Genetic Testing Prior Authorization - WRITE IN / TYPE IN (08/05/20)
Hysterectomy Consent (05/05/15)
VT Medicaid Child/Adolescent Inpatient Admission Notification - TYPE 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 - (See Foot Orthotic Tool, custom)
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)
- Vendor and Therapist Acknowledgement (07/01/19)
- Wheelchair Form : Positioning and Prescription Form (02/05/20)
- Wheelchair Form : Positioning and Prescription Form - TYPE IN (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