Forms & publications
Notice: If you are looking for Apple Health (Medicaid) client forms and publications, please visit our Free or low-cost forms library.
Negative pressure wound therapy
Form for requesting negative pressure wound therapy.
Download Negative pressure wound therapy
Download an alternate version of this form or publication
Alternate language versions:
Nucala request form
Use this form to request prior authorization for prescribing Nucala (mepolizumab SC injection).
Download Nucala request form
Download an alternate version of this form or publication
Alternate language versions:
Opdivo request form
Use this form to request prior authorization for prescribing Opdivo.
Download Opdivo request form
Download an alternate version of this form or publication
Alternate language versions:
Oral enteral nutrition assessment: dietitian worksheet
Dietitian worksheet is completed by the consulting dietitian and forwarded to the prescribing provider for approval and signature.
Download Oral enteral nutrition assessment: dietitian worksheet
Download an alternate version of this form or publication
Alternate language versions:
Oral enteral nutrition exception to rule request (ETR): adults
For metabolic disorders: oral enteral nutrition – adults. Oral enteral nutrition is not a covered benefit for adults 21 and older. Use this form to request an Exception to Rule (ETR). Complete the form in its entirety. A typed and completed General Authorization for Information form must be the cover sheet for your request in order to be processed by the Health Care Authority.
Oral enteral nutrition expedited prior authorization (EPA) form: thickeners for children from 1 – 20 years old
To be completed by the vendor and the prescribing provider.
Download Oral enteral nutrition expedited prior authorization (EPA) form: thickeners for children from 1 – 20 years old
Download an alternate version of this form or publication
Alternate language versions:
Oral enteral nutrition expedited prior authorization (EPA) worksheet: children
For metabolic disorders: oral enteral nutrition – children. Use this worksheet for EPA to request a metabolic formula for clients 20 years of age and younger.
Download Oral enteral nutrition expedited prior authorization (EPA) worksheet: children
Download an alternate version of this form or publication
Alternate language versions:
Oral enteral nutrition expedited prior authorization (EPA) worksheet: products for clients 20 years of age and younger
Use EPA when the client has an immediate need for an urgent supply of oral enteral nutrition product. The EPA can be used for a one-time, one-month supply to address a severe nutrition disorder. The prescribing provider must clearly identify the urgent condition and provide justification for why an immediate supply of the product is medically necessary.
Oral enteral nutrition prior authorization request (PAR) form: 20 years of age or less
Use this form to request prior authorization for clients 20 years of age or less. A typed and completed General Authorization for Information form must be attached to your request order to be processed by the Health Care Authority.