Forms & publications

Notice: If you are looking for Apple Health (Medicaid) client forms and publications, please visit our Free or low-cost forms library.

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

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 ambulance/secure transportation under the Involuntary Treatment Act (ITA)

42-0003

Use this form for mental health transports and for substance use disorder transports.

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

CUP women program preauthorization for limitation extension

12-344

Form for CUP women program preauthorization for limitation extension.

Form

Department of Corrections (DOC) authorization of release of information

Form

Enteral nutrition products prescription form (oral enteral nutrition)

13-961

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.

Form

Exondys 51 request form

13-0012

Use this form to request prior authorization to prescribe Exondys 51 (eteplirsen).

Form

Final transportation authorization

Form

Pages