Montana medical forms for physicians, PAs and APRNs

Workers' comp status reports, MVD driver and placard forms, Medicaid prior authorization, child care and sports forms, and FWP permits, with who completes each.

Montana's forms come from the Department of Labor & Industry, the Motor Vehicle Division, the Department of Public Health and Human Services, the Department of Revenue and Fish, Wildlife & Parks. Clinicians meet these most: the workers' comp Medical Status Form, the Disability Placard Application (MV5-DSB), the MHSA athletic preparticipation physical and Montana Medicaid prior authorization requests. This page lists all 27 Montana forms, grouped by program.

The treating provider completes a Medical Status Form after every office visit, and the office gives copies to the worker, the employer and the claims examiner. Montana Medicaid is fee-for-service with no managed care plans, so its prior authorization forms cover all members. For a medical marijuana card, a Montana MD or DO completes the PSDMC, and the patient uploads it in the TAP portal within 60 days of the assessment. Spanish versions exist for 2 of these forms.

Workers' compensation

All Workers' compensation forms

Medical Status Form

Formulario de Estado Médico

Documents the injured worker's current work capacity (full, modified, limited hours or off work), activity and lifting capacities, MMI/impairment status and follow-up after each visit, to support stay-at-work/return-to-work planning.

Completed by: Treating physician or designee (physician, chiropractor, PA, dentist, APRN or physical therapist under 39-71-116, MCA)
Issued by: Montana Department of Labor & Industry, Employment Relations Division (Workers' Compensation)
Format: Fillable PDF
Language: English and Spanish

Official page PDF Versión en español Form details

Physician's Referral to Domiciliary Care

Treating physician's referral establishing the need, services, hours, expected duration and physician oversight of domiciliary (home attendant) care for an injured worker.

Completed by: Authorized treating physician
Issued by: Montana Department of Labor & Industry, Employment Relations Division (Workers' Compensation)
Format: PDF
Language: English

Official page PDF Form details

Driver medicals

All Driver medicals forms

20-1900

Driver Medical Evaluation

Physician/provider evaluation of a condition MVD records indicate may affect safe driving, used for a licensing decision.

Completed by: Physician or other treating provider
Issued by: Montana Department of Justice, Motor Vehicle Division
Format: Fillable PDF
Language: English

Official page PDF Form details

22-1801

Eye Evaluation

Eye specialist's report verifying that a driver meets Montana vision standards for license issuance.

Completed by: Eye specialist (optometrist or ophthalmologist)
Issued by: Montana Department of Justice, Motor Vehicle Division
Format: PDF
Language: English

Official page PDF Form details

Disability parking and paratransit

All Disability parking and paratransit forms

MV5-DSB

Disability Placard Application

Applies for a permanent (5-year) or temporary (up to 2-year) disability parking placard, with a medical provider's certification.

Completed by: Licensed physician, physician assistant, chiropractor or APRN
Issued by: Montana Department of Justice, Motor Vehicle Division
Format: Fillable PDF
Language: English

Official page PDF Form details

MV5-VSB

Disability License Plate Application

Applies for physical disability license plates (permanent disabilities, MCA 49-4-301) with a medical provider's certification.

Completed by: Licensed physician, physician assistant, chiropractor or APRN
Issued by: Montana Department of Justice, Motor Vehicle Division
Format: Fillable PDF
Language: English

Official page PDF Form details

Medicaid

All Medicaid forms

DME CMN Motorized Wheelchair

Certificate of medical necessity for a motorized wheelchair under Montana Medicaid.

Completed by: Prescribing physician (with supplier/therapist)
Issued by: Montana Department of Public Health and Human Services (Montana Healthcare Programs)
Format: PDF
Language: English

Official page PDF Form details

Montana Medicaid Medical-Surgical Prior Authorization Request

Prior authorization request for medical and surgical services covering all providers in a single case.

Completed by: Requesting physician's office
Issued by: Montana Department of Public Health and Human Services (Montana Healthcare Programs); reviews by Mountain-Pacific Quality Health
Format: Fillable PDF
Language: English

Official page PDF Form details

DPHHS-SLTC-86

Level-of-Care Determination

Nursing facility and HCBS waiver level-of-care determination request with functional assessment.

Completed by: Referring facility/hospital clinician or case manager (physician information included)
Issued by: Montana Department of Public Health and Human Services, Senior and Long Term Care Division (reviewed by Mountain-Pacific Quality Health)
Format: Fillable PDF
Language: English

Official page PDF Form details

EPSDT Prior Authorization and Certification of Medical Necessity

PCP or specialist request and medical necessity certification for EPSDT services, supplies or drugs beyond standard coverage for members through age 20.

Completed by: Child's primary care provider or medical specialist
Issued by: Montana Department of Public Health and Human Services (Montana Healthcare Programs)
Format: Fillable PDF
Language: English

Official page PDF Form details

General Use Prior Authorization Form

General Montana Medicaid prior authorization request for services without a specific PA form.

Completed by: Requesting provider
Issued by: Montana Department of Public Health and Human Services (Montana Healthcare Programs)
Format: PDF
Language: English

Official page PDF Form details

School and child care health

All School and child care health forms

Pediatric Health Statement

Declaración de Salud Pediátrica

Medical professional's statement on a child's health required for enrollment in Montana licensed child care (ARM 37.95.128).

Completed by: Medical professional (physician, PA, APRN)
Issued by: Montana Department of Public Health and Human Services, Child Care Licensing Bureau
Format: PDF
Language: English and Spanish

Official page PDF Versión en español Form details

Health Care/Medication Plan

Care plan for a child with special health needs or ongoing medication in licensed child care, approved by the child's health care provider.

Completed by: Health care provider (approval and signature)
Issued by: Montana Department of Public Health and Human Services, Child Care Licensing Bureau
Format: PDF
Language: English

Official page PDF Form details

Sports physicals

All Sports physicals forms

MHSA Confidential Athletic Preparticipation Physical Examination

History, provider's physical examination and clearance required before participation in MHSA sports.

Completed by: Licensed medical professional acting within scope of practice
Issued by: Montana High School Association (MHSA)
Format: PDF
Language: English

Official page PDF Form details

Immunization and TB

All Immunization and TB forms

IZ HES101-S

State of Montana School Certificate of Immunization

Montana's official certificate of immunization for pre-K through 12th grade, recording vaccine dates and medical or religious exemption status.

Completed by: Health care provider, school official or parent transcribing from an official record (signs 'to the best of my knowledge')
Issued by: Montana Department of Public Health and Human Services, Immunization Program
Format: PDF
Language: English

Official page PDF Form details

HES 101A

Medical Exemption Statement

Documents vaccines for which a Montana student is medically contraindicated, with the contraindication or precaution for each.

Completed by: Qualifying health care provider: licensed in any US state or Canada, authorized to administer the vaccine, and who has treated the student or given the vaccine that caused a reaction (HB 334, 2021)
Issued by: Montana Department of Public Health and Human Services, Immunization Program
Format: Fillable PDF
Language: English

Official page PDF Form details

WIC and school meals

All WIC and school meals forms

Medical Statement for Children with Disabilities Requiring Meal Accommodations in the USDA Child Nutrition Programs

Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.

Completed by: State-licensed healthcare professional (physician, PA, APRN) or registered dietitian
Issued by: Montana Office of Public Instruction, School Nutrition Programs
Format: PDF
Language: English

Official page PDF Form details

WIC Infant Formula Request Form

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.

Completed by: Licensed health care provider with prescriptive authority (MD, DO, NP, PA)
Issued by: Montana Department of Public Health and Human Services, WIC Program
Format: Fillable PDF
Language: English

Official page PDF Form details

POLST and end of life

All POLST and end of life forms

POLST: Provider Orders for Life-Sustaining Treatment (Montana)

Portable medical order honored by EMS and facilities for CPR and scope-of-treatment decisions; also replaces Montana's Comfort One program.

Completed by: Physician, APRN or PA with the patient
Issued by: Montana Department of Public Health and Human Services, EMS and Trauma Systems Section
Format: PDF
Language: English

Official page PDF Form details

Medical cannabis

All Medical cannabis forms

PSDMC

Physician Statement for a Debilitating Medical Condition

Treating or referral physician certifies the applicant's debilitating medical condition, treatments tried, activity restrictions and the recommended period of use for a medical marijuana registry card.

Completed by: Montana-licensed MD or DO (treating physician or referral physician who assumed primary responsibility)
Issued by: Montana Department of Revenue, Cannabis & Alcohol Regulation Division
Format: Fillable PDF
Language: English

Official page PDF Form details

Cardholder Petition for Exception to Monthly Purchase Limits

Cardholder and certifying physician request a monthly purchase limit above the default 5 ounces (up to 8 ounces).

Completed by: Physician who signed the cardholder's written certification (MD/DO licensed in Montana)
Issued by: Montana Department of Revenue, Cannabis & Alcohol Regulation Division
Format: Fillable PDF
Language: English

Official page PDF Form details

PSDMC-Minor

Physician Statement for a Debilitating Medical Condition for Minors

Physician certification of a minor applicant's debilitating medical condition, with a second physician's concurrence unless the first is an oncologist, neurologist or epileptologist.

Completed by: Montana-licensed MD or DO (Part A/B) and a second physician (Part C)
Issued by: Montana Department of Revenue, Cannabis & Alcohol Regulation Division
Format: Fillable PDF
Language: English

Official page PDF Form details

Public health reporting

All Public health reporting forms

Adult Protective Services online intake report

Report of suspected abuse, neglect or exploitation of an older person or vulnerable adult.

Completed by: Mandated reporters (health care providers) and any concerned person
Issued by: Montana Department of Public Health and Human Services (DPHHS), Senior and Long Term Care Division, Adult Protective Services
Format: Online only
Language: English

Official page Form details

Hunting and fishing permits

All Hunting and fishing permits forms

2026 Permit to Modify Archery Equipment (PTMAE)

Medical provider's certification of a permanent lifetime condition (e.g. upper-limb impairment, coordination deficit) so the archer may use modified archery equipment (not crossbows) in archery season.

Completed by: MD, DO, DC, PA-C or APRN
Issued by: Montana Fish, Wildlife & Parks (FWP), Information Center
Format: Fillable PDF
Language: English

Official page PDF Form details

MCA 87-2-803

2026 Application for a Montana Resident with Disability Conservation License

Medical provider's certification that a Montana resident meets the permanent-disability criteria (e.g. non-ambulatory, documented genetic condition) for a reduced-fee Resident with a Disability Conservation License.

Completed by: MD, DO, DC, PA-C or APRN (genetic-condition criterion: MD/DO only)
Issued by: Montana Fish, Wildlife & Parks (FWP), Information Center
Format: Fillable PDF
Language: English

Official page PDF Form details

MCA 87-2-803(3)

Permit to Hunt from a Vehicle (PTHFV)

Montana-licensed medical provider's certification that a hunter is permanently and substantially non-ambulatory (or has a documented genetic condition) for a permit to hunt from a vehicle.

Completed by: Medical provider licensed in Montana: MD, DO, DC, PA-C or APRN (genetic-condition criterion: MD/DO only)
Issued by: Montana Fish, Wildlife & Parks (FWP), Information Center
Format: Fillable PDF
Language: English

Official page PDF Form details

More US forms

MedicaidState Medicaid programs180 forms Hunting and fishing permitsState wildlife agencies46 forms Medical cannabisState medical cannabis programs62 forms WIC and school mealsState WIC and school meal programs86 forms Driver medicalsState DMVs154 forms

How this list is checked

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.

Frequently asked questions

Who completes the Montana Medical Status Form?

The treating physician or a designee: a physician, chiropractor, PA, dentist, APRN or physical therapist under 39-71-116, MCA. The form records work capacity (full, modified, limited hours or off work), activity and lifting limits, MMI and impairment status, and follow-up. There are three versions of increasing detail, and you complete one per visit. After every visit the office gives copies to the worker, the employer and the claims examiner. A Spanish version is available.

How long is a Montana MHSA sports physical valid?

An MHSA physical done on or after May 1 is valid for the following two school years. In the off year, the student completes an interim history form instead. A licensed medical professional acting within their scope of practice completes the Provider's Physical Examination Form and Clearance, and the form goes back to the school.

Who can sign the Montana disability placard application (MV5-DSB)?

A licensed physician, physician assistant, chiropractor or APRN completes Section 1b. The form covers a permanent placard (5 years) or a temporary one (up to 2 years) for conditions expected to improve between six months and two years. There is no fee for the placard. Return it to the MVD by mail, fax or email. Disability license plates use a separate form, the MV5-VSB, filed with the County Treasurer.

What does a physician certify for a Montana medical marijuana card?

On the Physician Statement for a Debilitating Medical Condition (PSDMC), a Montana-licensed MD or DO certifies the condition, treatments tried, activity restrictions and the recommended period of use. Telemedicine assessments are allowed, and the form may not be modified. The patient uploads it in the Department of Revenue's TAP portal within 60 days of the assessment. Minors use the PSDMC-Minor, which needs a second physician in Part C unless the first is an oncologist, neurologist or epileptologist.