Search tip: To help find a specific form by number or key word, hold down the Ctrl key and select the F key. This will call up the "Find" dialogue box. Enter the number or title word(s) and select "Find Next."

Form Number
Title
Format
Modified Date
06-126 MHCP Multiple Premium Payment Adjustment PDF
09-013 Vendor Affidavit of Lost, Stolen, or Destroyed Warrant Word PDF April 2012
09-015 Core Provider Agreement Word PDF April 2013
09-016 Debarment Statement Word PDF August 2012
​09-019 Medicaid Administrative Claiming Time Study Sheet Word PDF ​August 2014
09-048 Provider Disclosure Statement Word PDF November 2012
09-559 Power of Attorney PDF
​12-200 Other Provider preventable Conditions (OPPC) Notification ​Word PDF ​June 2013
12-002  Authorization Agreement for Electronic Funds Transfer (EFT) Word   July 2011
12-003 Electronic Funds Transfer (EFT) Authorization Change Word   July 2011
12-325 School-Based Healthcare Provider Update Word PDF September 2014
12-333 Effective Date Change Request Form Word PDF March 2013
12-344 CUP Pre-Authorization for Limitation Extension Word   November 2012
12-411 Applied Behavioral Analysis (ABA) Level of Support Requirement Word PDF August 2013
​12-506 Washington Apple Health Administrative Hearing Rights and Deadlines
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
PDF ​May 2014
​12-507 Washington Apple Health Administrative Hearing Request – DSHS Classic Medicaid
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
PDF May 2014
​12-508 Washington Apple Health Administrative Hearing Rights and Deadlines - DSHS Classic Medicaid
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
​PDF ​September 2014
​12-511 Administrative Hearing Request – HCA/HBE
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
PDF ​May 2014
​12-512 ​Washington Apple Health Administrative Hearing Withdrawal
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
PDF ​June 2014
13-002​ Agreement for Nonbilling Individual Providers​ Word​ PDF
13-003​ Botulinum Toxin Request​ Word​ PDF August 2013​
13-364 Sterilization Consent Form
PDF Translations: Spanish
PDF
13-364A Client Statement Form (Sterilization)
PDF Translations: Spanish
PDF
13-365 Hysterectomy Consent and Patient Information PDF
13-658 Infant Case Management (ICM) Screening PDF
13-666 Orthodontic Information Word PDF June 2012
13-683 Well Child Exam - Infancy: 2-4 Weeks
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-683A Well Child Exam - Infancy: 2 Months
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-683B Well Child Exam - Infancy: 4 Months
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-683C Well Child Exam - Infancy: 6 Months
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-683D Well Child Exam - Infancy: 9 Months
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-683E Well Child Exam - Infancy: 12 Months
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-684 Well Child Exam - Early Childhood: 18 Months
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-684A Well Child Exam - Early Childhood: 2 Years
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-684B Well Child Exam - Early Childhood: 3 Years
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-684C Well Child Exam - Early Childhood: 4 Years
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-685 Well Child Exam - Late Childhood: 5 Years
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-685A Well Child Exam - Late Childhood: 6 Years
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-685B Well Child Exam - Late Childhood: 8 Years
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-685C Well Child Exam - Late Childhood: 10 Years
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-685D Well Child Exam - Late Childhood: 12 Years
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-686 Well Child Exam - Adolescence: 14 Years
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-686A Well Child Exam - Adolescence: 16 Years
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-686B Well Child Exam - Adolescence: 18 Years
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
PDF
13-691 Application for the Medicare Savings Program
PDF Translations: Cambodian, Chinese, Ilocano, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese
Word PDF January 2012
13-705 Health Insurance Premium Payment Program Application Word PDF July 2013
13-708 Voucher for Interim Pharmacy and Medical Services for Foster Children Word PDF April 2014
13-711 Treatment Questionnaire
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF August 2014
13-714 Pharmacy Statement (525-106) Word PDF
13-715 Pharmacy Adjustment Request (525-109) Word PDF December 2011
13-721 Justification for Use of Miscellaneous Parenteral Supply Procedure Code (B9999) Word PDF January 2013
13-726 Negative Pressure Wound Therapy Word PDF
13-727 Medical Necessity For Wheelchair Purchase (For Home Clients Only) Word PDF
13-728 Low Air-Loss Therapy Systems Word PDF
13-729 Medical Necessity For Wheelchair Purchase For Nursing Facility (NF) Clients Word PDF
13-730 Hospital Injury Report
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF
13-739 Vision Care Limitation Extension Word PDF February 2013
13-743 Oral Enteral Nutrition Worksheet Word PDF January 2013
13-745 Justification for Use of B9998 Miscellaneous Enteral Nutrition Procedure Code and Limitation Extension Request Word PDF January 2013
13-746 Medicaid Hospice Notification Word PDF January 2013
13-747 Hospital Bed Evaluation Word PDF June 2013
13-752 Pediatric Palliative Care (PPC) Referral & 5-Day Notification Word PDF January 2013
13-755 Airway Optical Ordering Form PDF
13-756 Fax/Written Request Basic Information Word PDF
13-760 Medical Necessity For Authorization of Catheters Word PDF
13-761 Oral Enteral Nutrition Worksheet Expedited Prior Authorization Request Word PDF February 2013
13-770 Request for Additional MG's of Synagis Word PDF July 2011
13-771 Request for Synagis Word PDF July 2011
13-772 Hearing Aid Limitation Extension Request Word PDF August 2011
13-781 Application for Take Charge (Family Planning) Services
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
  PDF April 2014
13-785 Bariatric Surgery Request Word PDF
13-786 Out Patient Rehabilitation Authorization Request Word PDF August 2011
13-787 Out of State Medical Services Request Word PDF
13-788 Denture/Partial Appliance Request For Skilled Nursing Facility Client Word PDF March 2012
13-789 Citizenship Documentation and Identity Declaration
PDF Translations: Burmese, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF September 2011
13-794 Health & Recovery Services Administration (HRSA) Prescription Form Word PDF
13-809 Denture or Partial Denture Agreement of Acceptance Word PDF August 2013
13-822 Extension Certification Authorization for Continue Word PDF
13-823 SSN Referral / Take Charge Word PDF
13-831 Durable Medical Equipment Word PDF
13-832 Tysabri (Natalizumab) Q4079 Request Word PDF
13-835 General Information for Authorization Word PDF August 2014
13-835A Pharmacy Information Authorization Word PDF December 2011
13-838 Acute Physical Medicine and Rehab Admit/Extension Request Word PDF July 2012
13-839 Acute Physical Medicine and Rehabilitation (PM&R) Update Word PDF
13-840 Patient Review and Coordination Referral Form Word PDF August 2011
13-841 Application For Chest Wall Oscillator Word PDF
13-843 Foster Care Initial Health Screen Word PDF
13-847 Home Health & Hospice (including PPC) Authorization Request Word PDF June 2012
13-849 Removable Prosthetic Prior Authorization Word PDF February 2013
13-850 Insomnia Referral Worksheet Word PDF
13-852A Xolair (Omalizumab) Request Word PDF March 2012
13-862 Enrollment Form
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish (Word Doc), Vietnamese
Word PDF September 2013
13-863 Tooth Chart Word PDF February 2014
13-864 HRSA Exception to Rule Request: Enteral Nutrition Word PDF
13-866 Diabetic Limitation Extension Request Word PDF July 2011
13-870 HRSA Limitation Extension Request: Incontinent Supplies Word PDF
13-871 HRSA Limitation Exception to Rule Request: Compression Garments Word PDF
13-872 HRSA Limitation Exception to Rule Request: Bathroom Equipment Word PDF
13-873 MSS Post Pregnancy Screening Tool Word PDF
13-874 MSS Prenatal Screening Tool Word PDF
13-879 Agreement to Pay for Healthcare Services
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF August 2012
13-882 HRSA Exception to Rule Request: TENS Unit and Associated Accessories Word PDF
13-884 Limitation Extension Request (Maternity Support Services and/or Infant Case Management) Word PDF
13-885 CIMZIA (Certolizumab pegol. Inj.) J0718 Request Word PDF November 2011
13-890 Long Term Acute Care Authorization/Update Request Word PDF February 2013
13-897 Remicade (Infiximab injection) J1745 Request Word PDF November 2011
13-898 Stelara (Ustekinumab injection) J3357 Request Word PDF November 2011
13-908 Oncotype DX Request Word PDF September 2014
​13-950 Non-Emergency Transfer Request Word PDF April 2014
​13-951 Mental Health Professionals Attestation Form Word PDF ​February 2014
​13-952

Retroactive Health Care Coverage Request - MAGI Medicaid
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese

PDF ​March 2014
​14-002 Authorization for Ambulance/Secure Transportation Under the Involuntary Treatment Act (ITA) ​Word ​PDF ​February 2014
14-194 Medical Coverage Information
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF August 2012
14-331 Provider Selection Word PDF August 2011
​14-430 Application for Pregnant Teen Health Care Coverage
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF ​November 2013
15-298 Oxygen and Respiratory Limitation Extension Word PDF February 2013
15-310 Speech Language Pathologist (SLP) Evaluation For Speech Generating Devices Word PDF
17-101A Billing Claim Forms Request Word PDF
17-184 Health and Recovery Services Administration Data Share Request Word PDF
​18-001P

Application for Health Care Coverage
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, SpanishTagalogVietnamese

Order Now

PDF

​January 2014
​18-002 Notice of Privacy Practices – HCA/HBE
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word ​PDF ​June 2013
​18-003 Health Care Coverage Rights and Responsibilities – HCA/HBE
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF ​January 2014
​18-005

Washington Apple Health Application for Long-Term Care/Aged, Blind, Disabled Coverage
PDF Translations:  Cambodian, Chinese, Korean, Laotian, Russian, Somali, SpanishTagalogVietnamese

Order Now ​PDF ​March 2014
​19-016 ​WA Apple Health Plan Choice
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF ​September 2013
​19-017 ​WA Apple Health Plan Choice
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF ​September 2013
​19-027 Washington Apple Health Request for Children in Tribal Foster Care PDF ​April 2014
​19-028 Washington Apple Health Request for Children Aging Out of Tribal Foster Care ​PDF ​April 2014
19-224 Gross Adjustments PDF
19-224A Gross Adjustments (MRS) PDF
20-272 HRSA Incident/Complaint Form Word PDF
​22-813 ​Health Homes Incident Report Word PDF ​May 2014
22-852​ Health Home Information Sharing Consent​
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF April 2014
22-853​ Health Home Opt-Out​​
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF March 2014
22-854​ Health Home Information Sharing Withdrawal​
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF August 2013​
27-033 Citizenship Affidavit (Tier 4)
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
Word PDF May 2012
​40-460 Notice of Privacy Practices
PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
PDF ​December 2013
80-020 Authorization for Release of Information Word March 2013