DMV driver and parking forms, the state's standard prior authorization forms, Medicaid requests, school and sports physicals, and DHHS social services forms.
Nebraska's forms come from the DMV, the Department of Health and Human Services, the Department of Insurance and the Nebraska School Activities Association. Clinicians meet these most: the Application for Handicapped Parking Permit, the school Physical Examination Report (FH-42) and Report of Visual Evaluation (FH-41), the NSAA pre-participation physical, and the two Nebraska Standard Prior Authorization Request Forms that all insurers must accept from January 1, 2026. This page lists all 31 Nebraska forms, grouped by program.
Send the standard prior authorization forms to the insurance carrier or its PBM, never to the Department of Insurance. Fee-for-service Medicaid has its own forms, and the MS-77 is void if the patient is in Heritage Health managed care. The DMV Statement of Physician (DMV 06-19) and Statement of Vision (DMV 06-18) are valid only for 90 days after the exam. Spanish versions exist for 8 of these forms, including the school health forms FH-31, FH-41, FH-42 and FH-43.
DMV 06-18Eye doctor reports acuity, visual field and lens type when a driver fails the DMV vision screening or is under vision review.
DMV 06-19Physician reports neurological, cardiovascular, diabetic, alcohol/drug and other conditions so the DMV can decide whether a driver or applicant may be licensed.
Physician's affidavit confirms a point-revoked driver must drive to ongoing medical treatment and has no reasonable alternative transportation.
Certifies a mobility, visual, respiratory or cardiac impairment so the applicant can get a permanent or temporary handicapped parking permit.
Certifies a qualifying disability so the DMV can approve handicapped license plates (and optionally a permanent permit).
Certifies a qualifying mobility disability for a veteran on the Nebraska Veterans Registry applying for military handicapped plates.
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.
Documents the visual evaluation required for school entry at the beginner grade and for out-of-state transfers (Neb. Rev. Stat. 79-214).
Convenience form documenting the physical examination required for school entry (kindergarten/beginner grade), seventh grade and transfers from out of state (Neb. Rev. Stat. 79-214).
Short provider certificate that the required school physical examination was completed (alternative to the full FH-42 report).
Preparticipation history, physical exam and clearance used for Nebraska school activities.
NSAA Formulario De Autorización De Conmoción Cerebral
Licensed health care professional's written clearance for a student removed for a concussion to return to play (Nebraska Concussion Awareness Act).
Medical Exemption Form - Spanish
Medical provider statement that immunization against listed diseases would be injurious to the student or a household member, exempting the student from Nebraska school/child care requirements.
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.
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.
Medical statement supporting a meal modification for a child or adult participant in the Child and Adult Care Food Program (child care centers, day care homes, adult day care), per 7 CFR 226.20(g).
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.
Enrolled health care practitioner's written recommendation (valid up to 24 months) and written order allowing a qualified patient to obtain medical cannabis from a licensed dispensary.
Report of suspected child abuse/neglect or abuse, neglect, self-neglect or exploitation of a vulnerable adult.
HHS-9-DCProvider report of a reportable disease, poisoning or organism under 173 NAC 1.
Qualified medical practitioner certifies that a homestead applicant is a totally disabled veteran (non-service-connected) or has a qualifying permanent disability (lost mobility without aid, >75% disability of both arms, bilateral arm amputation) for the Nebraska homestead exemption categories 2 and 3.
Qualified licensed medical practitioner certifies that a homestead applicant was an inpatient or incapacitated between February 2 and June 30, allowing a late homestead exemption application.
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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Yes. Under LB 77 (2025), all insurers and providers must accept the Nebraska Standard Prior Authorization Request Forms from January 1, 2026. One covers prescription drug benefits and durable medical equipment, the other health care services, including medical injectables. Each is a 3-page fillable PDF. Send it to the insurance carrier or its PBM, not to the Department of Insurance. Some carriers also offer an electronic version.
The DHHS Physical Examination Report (FH-42) documents the exam required for kindergarten or the beginner grade, seventh grade and transfers from out of state. The form itself notes that no specific form is required by statute. A physician, PA or APRN completes and signs it. The shorter Certification of Physical Examination (FH-43) can be used instead. Both come in English and Spanish and go back to the school health office.
A licensed physician, physician assistant or nurse practitioner completes the Medical Certificate section, certifying a mobility, visual, respiratory or cardiac impairment. One form covers permanent and temporary permits, renewals and replacements. The applicant files it with the city or village clerk or the designated county official. Handicapped license plates use a separate application mailed to the DMV, and plates are renewed every six years.
No more than 90 days after the exam. The applicant signs a release at the top, and the examining physician completes the rest: condition checklists for neurological, cardiovascular, diabetic, alcohol or drug and other conditions, a prognosis and a signature. The physician or the applicant mails or faxes it to the Nebraska DMV. Vision problems go on the Statement of Vision (DMV 06-18), completed by an optometrist or ophthalmologist.