- Many of the forms listed below have provider education presentations which can help providers with accurate form completion. The presentations also include guidance on each step of the process of submitting a request to Vermont Medicaid. The presentations can be found at: www.vtmedicaid.com/#/providerEducation.
- 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 (04/01/2025) - 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
- 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)
- 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)