Prior authorization requests, certificates of medical necessity, nursing facility level-of-care forms, and hospice and transport certifications from state Medicaid programs.
Each state runs its own Medicaid program, so the forms change at the state line. Prescribers meet the pharmacy prior authorization request most often, such as the Medi-Cal Rx Prior Authorization Request (DHCS 6560) or Illinois' uniform HFS 1409X. Next come certificates of medical necessity for equipment and oxygen, nursing facility level-of-care forms like Georgia's DMA-6 and North Carolina's FL2 (NC Medicaid-372-124), and certifications for hospice and non-emergency transport. This hub lists 180 forms, grouped by state.
Many requests start with someone else. DME suppliers, home health agencies and hospices send the form and need the prescriber's order, medical necessity section and signature. On Alaska's Certificate of Medical Necessity, the DME supplier may not complete the prescriber page. Some states want requests in a portal: MassHealth's PA-1 goes through POSC and Delaware's PA request through the DMAP Provider Portal. Of these forms, 3 have a Spanish version. Vero Documents turns any fillable PDF into a template the whole clinic can use.
General Alabama Medicaid prior authorization request for medical care, surgery, DME purchase/rental, home health visits, PT/OT and other non-pharmacy services.
General pharmacy prior authorization request for non-preferred or PA-required drugs not covered by a drug-specific form.
Documents admission and medical evaluation data used to establish that a nursing facility resident meets Alabama Medicaid long-term care admission (level of care) criteria.
Form 362Referral from the screening/primary provider for EPSDT-identified services, case management/care coordination or other referred care.
Form 384Required attachment to Form 342 documenting the PT/OT seating and mobility evaluation for manual and power wheelchair requests.
Form 168Physician certification that a Medicaid recipient is terminally ill for Medicaid hospice benefit periods.
Prescriber's certificate of medical necessity supporting a DMEPOS service authorization (items, diagnoses, length of need).
General medication prior authorization request, also used to exceed maximum allowed units, for drugs without a drug-specific form.
General Alaska Medicaid service authorization (prior authorization) request for medical services other than dental, long-term care and behavioral health.
Treating provider certifies medical necessity for Medicaid travel when the member bypasses the closest provider, travels out of state, or needs an adult or multiple escorts.
Requests or updates service authorization for Medicaid home health services with diagnosis and medical justification.
General prescription drug prior authorization/statement of medical necessity request for Arkansas Medicaid fee-for-service beneficiaries.
PCP or attending physician referral for evaluation or prescription of medically necessary OT/PT/speech therapy for Medicaid beneficiaries under 21.
Combined prescription and prior authorization request for Medicaid durable medical equipment (excluding wheelchairs and wheelchair components).
Seating and mobility evaluation and prescription supporting prior authorization of wheelchairs and wheelchair seating.
Medical need (level of care) assessment for nursing facility, ICF/ID, PACE, TEFRA and DAAS waiver programs.
PCP prescription/referral for medically necessary EPSDT services or items for beneficiaries under 21 that are not otherwise covered in the State Plan.
Prior authorization request for outpatient drugs under the Medi-Cal Rx pharmacy benefit (all Medi-Cal members, FFS and managed care).
Prior authorization request for enteral nutrition products under Medi-Cal Rx.
Health First Colorado prior authorization request (PAR) for outpatient services, DME, therapies and home health reviewed by Acentra Health.
General pharmacy prior authorization request for Health First Colorado fee-for-service outpatient drugs.
Certifies medical necessity (testing, flow rate, duration) for home oxygen under Health First Colorado.
Treating provider verifies why the member cannot be seen by a provider within 25 miles so long-distance NEMT can be authorized.
Licensed medical professional certifies the client's medical necessity as part of the long-term care functional assessment (nursing facility, ICF/IID or hospital level of care) for LTSS/HCBS eligibility.
Treating physician attests that a child has a life-limiting illness for enrollment in the Children with Life Limiting Illness (CLLI) waiver (10 CCR 2505-10 8.504.4.A.3).
General pharmacy prior authorization request for HUSKY drugs/products (non-preferred PDL drugs, brand medically necessary, early refills, quantity changes).
UMPR-FM115253-1023HUSKY Health prior authorization request for outpatient medical/surgical services, DME (incl. customized wheelchairs), chiropractic, therapies and other outpatient services.
Therapist-authored letter of medical necessity documenting the seating/mobility evaluation for wheelchair and wheeled mobility device requests.
General DMAP pharmacy prior authorization for non-preferred PDL drugs, quantity limit overrides and medical necessity requests.
Physician's medical report used to determine whether a long-term care Medicaid applicant meets nursing home level of care (facility or community).
Practitioner's statement of diagnosis, prognosis and medical necessity supporting DMAP coverage of supplies and durable medical equipment.
Fee-for-service DMAP prior authorization request for DME, home health care, surgery/diagnostic testing, therapies and other services.
DC fee-for-service Medicaid prior authorization request for surgery, DME, medical, pharmacy, dental, eyewear, hospice, home health and private duty nursing services.
Physician/APRN order prescribing long-term care services and supports (e.g. personal care aide, EPD waiver services) that triggers the DHCF LTCSS assessment.
Health care professional's medical certification used by CARES to determine medical (nursing facility level of care) eligibility for Medicaid institutional care (ICP) and long-term care/HCBS waiver, also usable as a patient transfer form.
Physician's recommendation and medical information used to establish nursing facility or ICF/ID level of care for Georgia Medicaid.
Physician certification of medical necessity (qualifying test results, flow rate) for Medicaid home oxygen equipment.
Physician certification of medical necessity, with PT/OT evaluation, for a Medicaid power wheelchair.
DMA 610Georgia Medicaid fee-for-service prior authorization request for DME, orthotics/prosthetics and case management services.
Physician's recommendation documenting a child's need for institutional level of care, used for TEFRA/Katie Beckett and pediatric level-of-care determinations.
Prior authorization request for Medicaid home health services, with the physician order and home health certification attached.
Prior authorization request for surgeries and procedures not reviewed by Idaho Medicaid's UM contractor (Telligen).
HFS 1409General Illinois Medicaid fee-for-service prior approval request for medical equipment, supplies and other services requiring prior approval.
Uniform pharmacy (and physician-administered drug) prior authorization request accepted by Illinois Medicaid fee-for-service and every HealthChoice Illinois MCO/PBM.
HFS 3701HSeating and mobility evaluation that serves as the letter of medical necessity for power mobility devices and custom wheelchairs.
HFS 3701TPrior approval request for physical, occupational and speech therapy under Illinois Medicaid fee-for-service.
HFS 3082Fee-for-service request for prior approval of a drug.
Universal nonpharmacy prior authorization request accepted by IHCP fee-for-service (Acentra Health) and every managed care entity (Hoosier Healthwise, HIP, Hoosier Care Connect, PathWays).
Physician certification of medical necessity for home oxygen under Indiana Medicaid.
Physician medical clearance documenting the need for a motorized wheelchair purchase under Indiana Medicaid.
State Form 48736Physician certification of terminal illness for the Indiana Medicaid hospice benefit.
General request for prior authorization of a non-preferred drug on the Iowa Medicaid Preferred Drug List.
Medical professional's certification that a member needs nursing facility or ICF/ID level of care before admission.
Common outpatient prior authorization request used for Iowa Medicaid fee-for-service and all Iowa Medicaid MCOs (Iowa Total Care, Wellpoint, Molina).
Provider attestation that an Iowa Health and Wellness Plan (expansion) member is 'medically exempt' (serious mental illness, SUD, complex medical condition, disability) so they can get full State Plan benefits.
Medical provider certifies a beneficiary's need for a specific level of non-emergency medical transportation.
General fee-for-service prior authorization request for medical services and items without a service-specific PA form.
Physician order and medical necessity documentation for blood glucose testing supplies under Kansas Medicaid.
Prior authorization request documenting medical necessity for a power wheelchair.
Documents medical necessity for EPSDT (KAN Be Healthy) services beyond State Plan limits for members under 21; lists FFS and each KanCare MCO's PA contacts.
Certificate of medical necessity attached to claims for items/services that require documentation of medical necessity.
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.
Uniform prescription drug prior authorization request used by Louisiana Medicaid fee-for-service and every Healthy Louisiana MCO under the single preferred drug list.
Prescriber's request and medical necessity attestation for Medicaid-covered disposable incontinence products.
Form # 20420General MaineCare pharmacy prior authorization request for non-preferred drugs and drugs subject to PA without their own form.
Prior authorization request for MaineCare-covered hearing aids.
Maryland Medicaid fee-for-service pharmacy prior authorization for age overrides, clinical criteria, non-preferred drugs and quantity limits (not for antipsychotics).
General MassHealth pharmacy prior authorization request for drugs on the MassHealth Drug List without a class-specific form.
Combined prescription and medical necessity review for DME and medical supplies, required with MassHealth DME PA requests and claims.
Member's primary care provider documents diagnoses and functional needs so the member can be evaluated for MassHealth personal care attendant (PCA) services.
Medical necessity certification for non-emergency ambulance or wheelchair van transport of a MassHealth member.
MassHealth fee-for-service prior authorization request for medical services, DME and other services requiring PA.
PCP order certifying that a member needs Adult Foster Care services.
Prior authorization request for DME, medical supplies, orthotics/prosthetics and other special services (non-mobility items) under Michigan Medicaid FFS/CSHCS.
Clinical evaluation and medical justification for complex seating systems, wheelchairs and mobility devices requested from Michigan Medicaid.
MSA-6544-BMichigan Medicaid fee-for-service (and CSHCS) prior authorization request for practitioner services.
BPHASA-2401Prescriber's medical justification for enteral nutrition therapy under Michigan Medicaid.
Home health agency request for prior approval of home health aide services under Michigan Medicaid.
Supplemental medical necessity documentation for wheelchair, scooter and mobility device authorization requests.
DHS-4695General paper authorization (prior authorization) request for Minnesota Health Care Programs fee-for-service services and equipment, used when the MN-ITS authorization transaction is not used.
2575-017General MO HealthNet pharmacy prior authorization request for drugs requiring clinical or PDL edits.
Physician certifies a participant's need for MO HealthNet personal care services.
2575-016Physician certificate of medical necessity supporting MO HealthNet coverage of DME and other items/services that require it.
2575-034MO HealthNet fee-for-service prior authorization request for medical services and durable medical equipment.
Physician certification of terminal illness for the MO HealthNet hospice benefit.
Certificate of medical necessity for a motorized wheelchair under Montana Medicaid.
Prior authorization request for medical and surgical services covering all providers in a single case.
DPHHS-SLTC-86Nursing facility and HCBS waiver level-of-care determination request with functional assessment.
PCP or specialist request and medical necessity certification for EPSDT services, supplies or drugs beyond standard coverage for members through age 20.
General Montana Medicaid prior authorization request for services without a specific PA form.
General fee-for-service pharmacy prior authorization, PDL exception, quantity-limit and high-dose override request.
Requests fee-for-service Medicaid utilization review/prior authorization for inpatient, outpatient, transplant, SNF and DME services.
Requests fee-for-service Nebraska Medicaid prior authorization of payment for items such as physician-administered injectables and other services listed in 471 NAC.
He-W 574 Form 1Health care professional determines the member's mobility needs and the appropriate mode of non-emergency medical transportation, for any NH Medicaid plan.
Requests approval of a non-preferred PDL drug for a NH Medicaid fee-for-service member.
Attending physician confirms the emergency nature of an encounter so it can be paid under the Medical Emergency Payment Program for Aliens.
Ordering provider documents the clinical reason and expected impact of a genetic or biomarker test so the lab claim can be paid.
Attending physician attests that a hospital stay was medically necessary and/or emergent for a Medicaid beneficiary.
Attending physician certifies that a Medicaid/NJ FamilyCare beneficiary is terminally ill with life expectancy of six months or less and needs hospice.
Standard prior authorization request for prescription drugs covered by NYRx for all New York Medicaid members, including those in managed care.
Medical practitioner certifies the mode of non-emergency transportation (e.g., taxi/livery, ambulette, stretcher) a Medicaid enrollee needs, registering it in the MAS system.
Worksheet prescribers use to prepare the enteral formula prior authorization they submit on the Enteral PA portal or IVR.
Treating provider describes diagnoses, findings and remaining functional capacity so the State Disability Review Unit can decide Disability Medicaid for applicants without an SSA determination.
Establishes the enrollee's need for Medicaid transportation to care available only outside the common medical marketing area.
Practitioner refers a beneficiary for a Personal Care Services independent assessment and attests to the medical need for PCS.
NC Medicaid-372-124Physician's level-of-care certification (FL-2) for nursing facility, adult care home and other long-term care placement.
NC Medicaid-372-131Combined certificate of medical necessity and prior approval request for durable medical equipment, orthotics/prosthetics and supplies under NC Medicaid Direct.
Standard pharmacy prior authorization / PDL exception request for NC Medicaid Direct beneficiaries.
Physician's signature page authorizing the level of care (e.g., nursing facility) requested for an NC Medicaid beneficiary through NCTracks.
Audiologist/physician requests NC Medicaid prior approval for hearing aids and related services.
DMA372-017AOptometrist/ophthalmologist requests NC Medicaid prior approval for eyeglasses or other visual aids beyond standard coverage.
NC Medicaid-3075Physician requests and justifies private duty nursing hours for a Medicaid beneficiary.
NC Medicaid-3402Requests EPSDT coverage of a service not covered by the State Plan (or beyond its limits) for a beneficiary under 21.
Member's medical provider certifies the medically appropriate mode of non-emergency medical transportation (e.g., wheelchair van, stretcher).
Requests authorization to exceed ND Medicaid service limits for chiropractic, PT/OT/speech therapy units and other limited services.
Requests ND Medicaid service authorization for surgical/medical procedures, devices and physician-administered drugs.
Prescriber documents medical necessity for medical supplies and equipment that need a CMN or need verification under Ohio Medicaid DMEPOS rules.
ODM 07137Qualifying treating physician certifies medical necessity (including the face-to-face encounter) for Medicaid home health services and/or private duty nursing under OAC 5160-12.
Prescriber certifies the need for incontinence garments and related supplies for an Ohio Medicaid individual.
HCA-12APaper prior authorization request for SoonerCare medical services, DME and other services needing PA, with prescribing physician's prescription and diagnosis.
CH-1 to CH-16Age-specific EPSDT well-child visit documentation templates covering history, screenings, exam, anticipatory guidance and referrals.
Certifies that non-emergency ground or air ambulance transport is medically necessary for a SoonerCare member.
Physician certifies medical necessity for home oxygen equipment for a SoonerCare member.
Physician orders diapers, pull-ons, liners, underpads, wipes and gloves for a SoonerCare child aged 4-20.
Requests SoonerCare prior authorization for physical, occupational and speech therapy.
Universal petition for medication prior authorization when no drug-specific form applies.
Coversheet and request form for fee-for-service OHP prior authorization of physical health services, DME, imaging and other services.
General fee-for-service OHP prior authorization request for prescription drugs and oral nutritional supplements.
Speech-language pathologist's evaluation summary that justifies a speech-generating/augmentative communication device for OHP prior authorization.
Clinical justification for a standing positioner (stander) requested under OHP fee-for-service DME prior authorization.
Physician's medical evaluation and plan of care supporting Medical Assistance payment for nursing facility (and ICF) level of care.
Physician certifies the clinical need for nursing facility level of care, used in Community HealthChoices / home and community-based waiver eligibility.
General fee-for-service request for a non-preferred drug on the Pennsylvania Statewide Preferred Drug List.
Requests fee-for-service Medical Assistance prior authorization or a program exception (1150 waiver) for outpatient services, DME and supplies.
Physician certifies terminal illness so a Medical Assistance recipient can elect the hospice benefit.
Universal pharmacy prior authorization request for South Carolina Medicaid members, with fax numbers for fee-for-service and each managed care plan.
Screens nursing facility applicants for serious mental illness or intellectual/related disability before admission, including attending-physician certification for exempted hospital discharges.
General South Dakota Medicaid prior authorization request for medical services, submitted with supporting medical records.
Requests South Dakota Medicaid prior authorization for durable medical equipment and nutrition products.
Requests prior authorization of private duty nursing or extended home health aide services, submitted with a physician-signed plan of care.
Ordering provider requests South Dakota Medicaid prior authorization for genetic testing.
Physician certifies the medical necessity of an abortion (life endangerment, rape or incest exceptions) for TennCare payment.
Treating provider certifies that the standard appeal timeframe could seriously jeopardize the member's life, health or ability to regain maximum function, so a TennCare medical appeal is expedited.
Prescribing provider's order and medical necessity statement for Texas Medicaid home health DME and medical supplies.
F00139Requests Texas Medicaid prior authorization for outpatient PT, OT and ST evaluations and treatment.
Prior authorization request for Comprehensive Care Program (EPSDT/Texas Health Steps) services, equipment and supplies for Medicaid clients under 21.
Physician-signed plan of care used to prior authorize Texas Medicaid home health skilled nursing, aide and therapy visits.
Requests Texas Medicaid special medical prior authorization for procedures and services that require PA (e.g., certain surgeries, transplants, bariatric surgery).
Seating assessment and medical justification for manual/power wheelchairs, scooters and strollers under Texas Medicaid CCP or home health.
Prescriber documents qualifying oxygen saturation/ABG results and orders for home oxygen equipment and supplies.
Physician's ear examination and medical clearance for a Texas Medicaid hearing aid evaluation and fitting.
Standard Vermont Medicaid prior authorization request for medical services, procedures and equipment.
General Vermont Medicaid pharmacy prior authorization request for medications that require PA.
Clinical positioning evaluation and prescription supporting Vermont Medicaid prior authorization of a positioning (complex) wheelchair.
Ordering clinician requests Vermont Medicaid prior authorization for genetic testing.
Requests fee-for-service Virginia Medicaid service authorization for procedures and devices (including DME).
Requests fee-for-service Virginia Medicaid service authorization for outpatient services such as rehabilitation therapy, home health and imaging.
HCA 13-835Required first page for any Apple Health fee-for-service medical, DME or dental prior authorization or limitation extension request faxed to HCA.
HCA 13-835AFee-for-service Apple Health pharmacy prior authorization or limitation request for a prescription.
HCA 13-847Requests Apple Health authorization for home health skilled nursing and therapy visits.
Medical justification to exceed Apple Health quantity limits for incontinence supplies.
Prescriber's order and medical justification for oral enteral nutrition products for Apple Health clients.
HCA 13-747Clinical evaluation supporting Apple Health authorization of a hospital bed.
HCA 13-772Requests Apple Health authorization for hearing aids and related services.
General West Virginia Medicaid pharmacy prior authorization request for drugs needing PA where no drug-specific form applies.
Cover request form required with most Wisconsin Medicaid/BadgerCare Plus fee-for-service prior authorization requests (with a service-specific attachment).
Prescriber and DME provider document medical necessity for durable medical equipment needing prior authorization.
F-01068A to F-01068LAge-specific HealthCheck (EPSDT) well-child visit documentation templates from the 3-4 week visit through the teenager visit.
Medical care provider certifies a member's need for specialized medical vehicle (wheelchair van) transportation.
General prior authorization attachment for drugs that need PA where no drug-specific form exists.
Prescriber documents diagnosis, growth/nutrition status and medical need for enteral nutrition formula needing prior authorization.
Requests coverage of a non-preferred drug on the Wisconsin Medicaid Preferred Drug List.
Physician's otological examination report supporting prior authorization of hearing instruments for a Wisconsin Medicaid member.
Documents the plan and medical need for home health physical, occupational or speech therapy needing prior authorization.
Prescriber documents qualifying oxygen testing and medical need for home oxygen needing prior authorization.
Physician/provider summarizes history, exam, labs and imaging to document the medical necessity of a prescribed service, including out-of-state services.
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.
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To Medi-Cal Rx, not the patient's managed care plan. Medi-Cal Rx handles outpatient pharmacy prior authorization for all Medi-Cal members. Submit the DHCS 6560 through CoverMyMeds, the Medi-Cal Rx Provider Portal PA tool, NCPDP P4 at the point of sale, fax or mail. The four pages ask for the member, requestor, medication, prior therapies, ICD-10 diagnoses and clinical information. Enteral nutrition has its own form, the DHCS 6505.
The prescriber completes the medical necessity part, and the supplier may fill in some identifying details, depending on the state. On the Alaska Medicaid CMN General Prescriber Page, the ordering physician, PA, NP or audiologist completes the page, and the DME supplier may not fill in Section B onward. Ohio's ODM 01913 lets the supplier complete the identifying section. The supplier keeps the signed CMN or attaches it to its prior authorization request.
In this library, Delaware's fee-for-service Prior Authorization Request Form must be submitted on the DMAP Provider Portal at least two weeks before the date of service. MassHealth's PA-1 normally goes through the Provider Online Service Center, with paper only under an approved waiver. Colorado's outpatient PAR goes through the Acentra Health Atrezzo portal unless the provider is approved to fax. Michigan prefers CHAMPS direct data entry for the MSA-6544-B.
Usually both the attending physician and the hospice medical director. Alabama's Hospice Certification (Form 168), Indiana's Medicaid Hospice Physician Certification (State Form 48736), Missouri's 2575-031, New Jersey's FD-385 and Pennsylvania's MA 372 all list both signers. New Jersey's form certifies a life expectancy of six months or less. The hospice keeps the signed certification with the election statement or submits it with the election packet.