The 40 Kentucky forms clinicians complete, from workers' claims reports and school entry exams to Medicaid prior authorization, the MOST and 72-hour hold certifications.
This page lists the Kentucky forms clinicians complete, grouped by program, and each group links to its program hub. In workers' comp, the Department of Workers' Claims uses Form 107, the physician's medical report for injury, hearing loss or psychological claims, and Form 108-OD for occupational disease. Schools ask for the KDESHS002 preventive exam, the KDESHS004 eye exam and the EPID 230 Certificate of Immunization Status. Every Kentucky Medicaid member's drug requests go on one Universal Prior Authorization Form through the single state PBM.
Form 107 requires an AMA Guides impairment rating and goes in with the physician's CV unless the physician has a Physician Index Number. A designated physician accepts the role on Form 113. EPID 230 doubles as the medical exemption, so there is no separate form. Involuntary hospitalization runs on AOC forms filed with the district court, starting with AOC-712 for a 72-hour hold. The MOST and the KHSAA physical come in Spanish. Vero Documents fills PDF forms from the visit note and the chart.
Physician's litigation medical report used by administrative law judges: history, examination, testing, diagnosis, causation, AMA Guides whole-person impairment, MMI date and restrictions for injury, hearing loss or psychological claims.
Form 108-ODPhysician's litigation report for occupational-disease claims (including pneumoconiosis and other lung or heart disease): history, exposure, examination, ILO-classified x-rays and testing, diagnosis, causation, AMA Guides impairment and restrictions.
Form 113Names the employee's designated physician, who coordinates all work-injury care and referrals, and records the physician's acceptance and the employee's medical-information release.
Physician's opinion on whether continued medical treatment is reasonably necessary for the work injury or occupational disease, supporting an application to continue medical benefits beyond the statutory cut-off.
Physician's history, exam, diagnosis, functional impact, treatment and conclusion whether a TRS Kentucky member is disabled (12-month job-duty test or total and permanent duty-related test) for disability retirement and disability retiree reviews.
TC 94-202Reports a vision examination done for driver vision testing before an initial permit, initial license, renewal or reinstatement (KRS 186.577), including failures referred to the Medical Review Board.
TC 94-38A to TC 94-38GCondition-specific medical reports supporting an intrastate CDL medical waiver for applicants who do not meet federal DOT physical standards.
Physician's statement on whether a driver has a medical condition preventing use of a breath alcohol ignition interlock device, submitted with the Kentucky Ignition Interlock Program application.
TC 94-182Reports a driver with a physical or mental impairment to the Medical Review Board, which then opens a case and sends medical forms to the driver.
Applies for a disabled license plate or a permanent or temporary disabled parking placard, with certification of the disability.
Universal pharmacy prior authorization request for any drug, used for all Kentucky Medicaid members under the single state PBM (FFS and managed care).
Physician (or authorized professional) certification that non-emergency ambulance transport is medically necessary because other transport is contraindicated.
Physician/APRN/PA certification of medical necessity for disposable medical supplies provided through a home health agency.
Physician/APRN/PA recommendation that a person needs 1915(c) waiver services (HCB, ABI, ABI long-term care, SCL, Michelle P.), part of waiver level-of-care eligibility.
Attending physician certifies that a hospital patient needs a short nursing facility stay (under 30 days) for the condition treated, exempting them from PASRR Level II at admission.
Documents the preventive health care examination required within 12 months before first entering a Kentucky public school and within one year before entry to sixth grade (702 KAR 1:160).
Proof of the vision examination required (KRS 156.160) by January 1 of the first year a child aged 3-6 enrolls in public preschool or primary school.
Proof of the dental screening or examination required (KRS 156.160) for children aged 5 and 6 entering public school.
Medical examination (with TB screening) required for school employees under 702 KAR 1:160.
GE04 / PPE01Required parent permission and medical consent with the provider's medical clearance, plus the optional PPE01 history and physical exam, for KHSAA high school athletics.
Written authorization from a provider before an athlete removed for a suspected concussion returns to play (KRS 160.445).
Physician documentation that a wrestler's skin condition is non-communicable so the wrestler may compete.
Required certificate on file at every Kentucky child care facility and school showing a child's immunizations and current status with an expiration date; marked as a medical exemption for temporary or permanent contraindications.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Standardized medical order for scope of treatment (CPR, interventions, nutrition) under KRS 311.6225.
Sworn certification by a qualified mental health professional that a person meets criteria for emergency 72-hour involuntary hospitalization under KRS 202A.
Qualified mental health professional's examination certificate supporting a 60-day or 360-day involuntary hospitalization petition (KRS 202A).
AOC-703AQualified health professional's certification supporting a Casey's Law petition for 60/360-day involuntary substance use disorder treatment (KRS 222.430-.437).
Examiner's certificate in KRS 202C involuntary commitment proceedings (persons with intellectual disability found incompetent to stand trial and dangerous).
Examination certificate supporting involuntary admission of a person with an intellectual disability to an ICF/IID under KRS 202B.
Qualified mental health professional's evaluation certifying whether a respondent meets criteria for court-ordered assisted outpatient treatment (Tim's Law, KRS 202A.0815).
Authorized practitioner records a written certification that the patient has a qualifying condition likely to benefit from medical cannabis, enabling a registry card application.
Non-emergency online report of suspected abuse, neglect or dependency of a child, or abuse, neglect or exploitation of an adult, in Kentucky.
EPID 200Case report of a disease or condition reportable under 902 KAR 2:020 (also used for confidential STD case reports) to the local health department.
Reports hepatitis B or C infection in a pregnant woman or in a young child (HBV <=2 years, HCV <=3 years), including the newborn/infant born to an infected mother.
Reports an HBsAg-positive pregnant or postpartum mother and the exposed infant's HBIG/hepatitis B vaccine and follow-up for the perinatal hepatitis B prevention program.
Kentucky-licensed physician's attestation of a severe mobility impairment (paralysis, amputation, wheelchair/crutches, lung or cardiac limits, etc.) for vehicle access on designated wildlife management areas.
Licensed physician's attestation that a hunter cannot use conventional archery equipment and must use a crossbow during bow-only deer season, with temporary/permanent duration.
Licensed physician's attestation that a hunter must hunt from an ATV or other vehicle (private property) because of a temporary or permanent disability.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Form 107 is the physician's medical report that administrative law judges use in injury, hearing loss and psychological claims. A treating or evaluating physician covers history, exam, testing, diagnosis, causation, AMA Guides whole-person impairment, the MMI date and restrictions. One combined form replaced the older 107-I, 107-HL and 107-P. The party offering it files it in the claim. Occupational disease claims use Form 108-OD.
EPID 230 can be signed by a physician or APRN licensed in any state, a Kentucky PA or pharmacist, a local health department, a licensed health facility or a Kentucky Immunization Registry user, and an RN or LPN designee may sign. It records vaccine dates, status and an expiration date. For a contraindication, the certificate is marked as a temporary or permanent medical exemption. EMR and registry printouts are accepted if they match the format.
Yes. A printed MOST must be a single double-sided 8.5 x 11 sheet, and any color is fine. Printed and electronic versions are equally valid, and the form stays with the patient. A physician, APRN or PA completes the orders with the patient or surrogate, and a Spanish version exists. The separate EMS DNR order, signed by the attending physician, no longer needs a notary or witnesses.
A qualified mental health professional as listed in KRS 202A.011, including physicians, psychiatrists, psychologists, APRNs, PAs, LCSWs, LPCCs and LMFTs. AOC-712 is a sworn affidavit that the person meets criteria for emergency 72-hour involuntary hospitalization, and it is filed with the district court. For a 60-day or 360-day petition, the examiner uses AOC-720A, and two certifications, one by a psychiatrist, are typically required.