The Department of Vermont Health Access uses this uniform form for Vermont Medicaid prior authorization of medical and mental health services, procedures, therapies, imaging and equipment. Vermont Medicaid has no managed care plans, so DVHA's clinical unit reviews every request. A clinician meets it when ordering a service that needs approval, and must send it with clinical documentation supporting medical necessity.
The requesting provider's office completes the form, naming the referring or requesting provider, the rendering or attending provider and the person completing it. Required fields are marked with an asterisk.
Download the current version from the source each time; forms change without notice.
Uniform Medical Prior Authorization Form
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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Date of request, type of service, place of service including telehealth, date diagnosed, proposed dates, the facility, proposed inpatient days or outpatient visits, primary and secondary diagnoses with codes, and the procedure with its CPT, HCPCS or revenue code. Attach records supporting medical necessity and note the number of pages.
DVHA's clinical unit. Vermont Medicaid has no managed care organizations, so DVHA reviews prior authorization requests directly. Mental health requests go to a separate DVHA fax line from other clinical requests, and DVHA notes that for EPSDT requests for members under 21, a Medicaid-enrolled provider should submit the request.