Forms & publications

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Acute inpatient rehabilitation authorization update

13-839

Acute physical medicine and rehabilitation (PM&R) update form.

Form

Acute physical medicine and rehab admit/extension prior authorization request

13-838

Use this form to request admission or extension for acute physical medicine and rehab services.

Form

Application for chest wall oscillator

13-841

Application for a chest wall oscillator.

Form

Applied Behavior Analysis (ABA) level of support requirement

12-411

Use this form to request authorization. A copy of the COE evaluation, the prescription for ABA services, the Board Certified Applied Behavior Analyst’s (BCABA) assessment with the functional analysis, and the BCBA’s treatment plan must be attached to this request.

Form

Authorization for Transportation to an Evaluation and Treatment Facility

13-680

Use this form when transporting a mental health or chemical dependency client from the field directly to an evaluation and treatment facility.

Form

Bariatric surgery request

13-785

Use this form to request stage 2 bariatric surgery services.

Form

Bathroom equipment authorization form (13-872)

13-872

Use this form to request and provide medical justification for bathroom equipment.

Form

Botulinum Toxin Request​

13-003

Form

Cimzia (Certolizumab pegol. Inj) J0717 request

13-885

Form

Compression garments authorization form (13-871)

13-871

Use this form to provide medical justification and request compression garments.

Form

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