Clinical Forms and Prior Authorization Forms

Applied Behavior Analysis
Behavioral Health
Chiropractic
Durable Medical Equipment

Please use the Medical Necessity, General form found below when there isn’t a specific form for requested service or equipment.

Laboratory and Radiology
Out-of-Network
Pharmacy
Procedures
Therapy
Uniform Medical Prior Authorization Form

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