Workers' comp medical forms, DMV driver and walking disability forms, the uniform prescription prior authorization form, POLST and therapeutic cannabis certifications.
New Hampshire's forms come from the Department of Labor, the Division of Motor Vehicles, the Department of Health and Human Services, the Insurance Department and the courts. Clinicians meet these most: the Workers' Compensation Medical Form (75 WCA-1), the Uniform Prior Authorization Form for prescription drug requests, the DMV Eye Examination (DSMV 61) and the Application for Walking Disability Privileges (RDMV 130). This page lists all 30 New Hampshire forms, grouped by program, including school bus driver physicals and POLST.
The 75 WCA-1 is due at every visit: file it with the workers' comp carrier within 10 days of each treatment, or the provider is not reimbursed. Insurers and PBMs must accept the uniform prescription prior authorization form and may not ask for more than it covers. The DSMV 61 is valid only 30 days after signing. POLST and portable DNR orders must be on the official bright yellow and bright pink forms from the Foundation for Healthy Communities.
Health professional's report at every visit of diagnosis, causation, treatment plan, work capability and restrictions, MMI and permanent impairment, supporting temporary alternative work under RSA 281-A:23-b.
Physician certifies a worker's preexisting permanent impairment, the subsequent work injury and whether the combination causes greater disability (or death), supporting an insurer's Second Injury Fund reimbursement claim (RSA 281-A:54).
PFML-CERT-FORM-NHCertifies the employee's own or a family member's serious health condition (diagnosis/ICD-10, treatment dates, expected duration, hospitalization, intermittent schedule) for a voluntary NH PFML insurance claim.
Physical examination and Licensed Physician's Certificate for a driver education instructor applicant.
DSMV 61Eye doctor records acuity without lenses, with old and with new lenses and recommends whether the applicant is visually capable of a NH license (min. 20/40 both eyes or 20/30 one eye); Part C covers the special 20/40-20/70 visual acuity requirements under Saf-C 1004.08.
DSMV 649Physical examination (vision, hearing, reflexes, 5-year illness history) and Licensed Physician's Certificate for a NH school bus certificate applicant.
Lets a NH licensee temporarily out of state have the required visual acuity test done by an authorized licensing examiner or eye doctor where they are, to renew the license.
Intrastate commercial driver who does not meet 49 CFR 391.41 applies for a NH waiver (up to 2 years); includes a Medical Evaluation Summary by a licensed physician per Saf-C 909.07.
Physician states the medical condition, how aftermarket window tinting alleviates it and certifies medical necessity (RSA 266:58-a, Saf-C 2500); option for a waiver of 4+ years.
Licensed physician certifies a diagnosis of autism spectrum disorder, deafness/hard of hearing or another disorder authorized in RSA 263:41-b so it is indicated on the NH license or non-driver ID.
Medical provider certifies a temporary (up to 6 months) or permanent walking disability (RSA 259:124, 261:88) for walking disability placards or plates.
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.
Certification that immunization against a particular disease may be detrimental to the child's health, valid for the period the provider specifies (RSA 141-C:20-c).
Records a child's length or height, weight, hemoglobin or hematocrit and lead results from the provider's office so the family can supply them for WIC participation.
Portable medical order (bright yellow) recording resuscitation and treatment decisions; can serve as a DNR order without a separate form.
Statutory out-of-hospital DNR order (bright pink form or wallet card) honored by EMS; required for a DNR bracelet or necklace.
Petition and examining clinician's certificate for involuntary emergency admission (IEA) of a person who is a danger to self or others because of mental illness (RSA 135-C:27-28).
Same certifying provider extends an existing written certification (total not to exceed 3 years) without a new application or fee.
Certifying provider attests to a provider-patient relationship and the patient's qualifying medical condition (diagnosis plus qualifying symptom, or stand-alone condition) for an initial or renewal registry ID card.
Second certifying provider for a minor attests to qualifying as a 'pediatric care provider' when not a pediatrics/family medicine specialist (e.g. PA on a pediatric team or provider with extensive pediatric experience).
Certifying provider rescinds a previously issued written certification for cause (no qualifying condition, should discontinue, falsified information, non-adherence, other).
General report of a reportable infectious disease (other than those with a disease-specific form) under RSA 141-C and He-P 300.
Provider report of a sexually transmitted infection with treatment given and pregnancy status.
Report of suspected abuse, neglect, exploitation or self-neglect of a vulnerable adult under the Adult Protection Law.
Provider case report of HIV infection or AIDS in an adult or adolescent.
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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At every visit except first aid. The treating MD, DO, DC or DDS completes the health professional section: diagnosis, causation, treatment plan, work capability and restrictions, MMI and permanent impairment. File it with the workers' comp carrier within 10 days of each treatment, with copies to the insurer or managed care, the employee and the employer. Attach all medical notes to the bill. A provider who does not file is not reimbursed and may face a civil penalty.
Yes, for prescription drugs. Under RSA 420-J:18 and Ins 2705, insurers and PBMs must use and accept the New Hampshire Uniform Prior Authorization Form and may not require information beyond it. The insurer prefills section A. The prescriber completes sections B to G (request type, patient, prescriber, medication, clinical information, rationale) and signs. Fax or send it electronically to the insurer or PBM named in section A.
A licensed physician, podiatrist, APRN or physician assistant completes Section II of the Application for Walking Disability Privileges (RDMV 130). The form covers a temporary walking disability of up to 6 months or a permanent one, for placards or plates. Placard applications go to the DMV, and plates go through the town or city clerk. Permanent placards need periodic recertification.
An NH physician, APRN or PA with DEA registration; another NH prescriber primarily responsible for the condition, such as a dentist, podiatrist, optometrist or naturopath; or a Maine, Massachusetts or Vermont physician, APRN or PA primarily responsible for it. The patient mails the Written Certification with the application, and it is accepted up to 6 months after signing. Minors need two providers, one a pediatric care provider. The same provider can extend a certification without a new application.