Forms

Instructions are included with the forms listed below.

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Forms

TitleDescriptionFile SizeFile Type
Administrative Medication Review (AMR) Authorization Form (High Priced Medical Drugs)Effective Start Date: March 01, 2020816 KB.pdf
BRCA Prior Authorization Fax Form- WordEffective 8/1/2019 18 KB.docx
BRCA Prior Authorization Request Form -PDFEffective 8/1/2019270 KB.pdf
Certificate of Necessity Cranial RemodelingJune 2012108 KB.pdf
DME Checklist 19 KB.docx
FQHC Required Mental Health FormUpdated 03/201440 KB.pdf
Inpatient Psychiatric ChecklistSubmitting clinical information 3/21/201315 KB.docx
Inpatient Acute ChecklistSubmitting Clinical information 3/21/201321 KB.docx
Inpatient Rehab checklistSubmitting Clinical information 3/21/201320 KB.docx
Lip Prior Authorization Fax FormUpdated 02/25/201439 KB.docx
Mental Health ChecklistPosted 01/20/201415 KB.docx
Outpatient Prior Authorization Request Fax formUpdated August 201849 KB.docx
Prior Authorization Fax Form - Transplant and Surgical JustifcationRevised 6/2012184 KB.doc
Prior Authorization Fax Form -PRTFPRTF Fax Form62 KB.docx
Prior Authorization Fax Form- Inpatient requestRevised 7/1/201449 KB.docx
PRTF/ Freestanding Psych- Certificate of NeedEffective 7/1/201416 KB.docx
Required DHS 149 Election Form HospiceNew 9/24/201219 KB.pdf
Required DHS 151 Hospice Physician Certification/Recertification Form New 9/24/201220 KB.pdf
Required DHS 152 Hospice Change Request FormNew 9/24/201218 KB.pdf
Required DHS 153 Hospice Revocation Form New 9/24/201217 KB.pdf
Required DHS 154 Hospice Discharge Form New 9/24/201214 KB.pdf
Required Document - DME (Wheelchair and Accessories)New - 5/2012107 KB.pdf
Required Document- Physicians Mental Health FormUpdated 01/201453 KB.pdf
Required Documentation - TransplantRevised - 6/20121645 KB.pdf
Required Documentation- Sterilization Consent FormUpdated 05.2017168 KB.docx
Required LIP AuthorizationRevised - 6/20121502 KB.pdf
Required LIP ReferralRevised - 6/201255 KB.docx
Required Medcial Necessity Physician ReferralRevised - 6/201258 KB.docx
SC Surgical Justification and Sterilization Forms 922 KB.pdf
SCDHHS Prior Authorization Form for Fetal DNA Blood Test ( Fetal Testing)Effective Start Date: February 01, 202070 KB.docx
Transplant Instructions for Prior AuthorizationRevised 6/2012872 KB.pdf

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