Workers' comp, DMV, Medicaid, immunization, WIC, end-of-life, emergency exam, cannabis and Fish & Wildlife forms from Vermont agencies, with who completes each.
Vermont's clinician forms come from the Department of Labor, the DMV, the Department of Vermont Health Access (DVHA), the Department of Health and the Department of Mental Health. The ones practices see most are the Vermont DNR/COLST form, the DMV's Universal Medical Evaluation/Progress Report (VS-113), DVHA's Uniform Medical Prior Authorization Form, and the workers' comp Health Care Provider Report (HCP1) and Work Capabilities Form (Form 20). This hub lists 33 forms.
The VS-113 is one form for license medicals, Type II school bus endorsements and disabled parking plates. The single DNR/COLST form serves as both the EMS DNR and the clinician orders for life-sustaining treatment. Vermont Medicaid has no managed care plans, so DVHA reviews every prior authorization, and several DVHA forms are Word files. An emergency psychiatric exam needs a physician's first certificate and then a psychiatrist's second certificate. Upload any fillable PDF to Vero Documents and it becomes a template the whole clinic can use.
Form 20Recommended form for medical providers to document an injured worker's physical work capabilities (stand, sit, lift, bend, reach, hours) or total disability and duration.
Treating provider's report of the work injury: complaints, diagnosis, work-relatedness, causal opinion, tests, treatment plan, medications and work capacity/restrictions.
Optional request by a health care provider for insurer preauthorization of proposed treatment, with medical-necessity letter and work-relatedness explanation (21 V.S.A. s.640b).
Documents a patient's cognitive, self-regulation and resilience work capabilities on a 1-5 scale with suggested job modifications, for return to work and disability benefits.
Requests insurer preauthorization of medical case management services, supported by a health care provider's recommendation (21 V.S.A. ss.601(31)(C), 640b).
One medical form used for license/permit applications, new or updated medical conditions, Type II school bus endorsement and disabled parking plate/placard eligibility.
Vermont-licensed eye doctor reports acuity, color vision, ocular coordination and fields when DMV requires an eyesight examination to grant or keep a license.
Physician or optometrist certifies the clinical diagnosis, recommended visible light transmittance and duration (4-year or indefinite) for a medical window tint permit.
Clinician certifies a temporary ambulatory handicap and recommends a placard expiry (6 months maximum, not renewable).
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.
Physician release allowing a wrestler with a skin infection to compete.
Medical (page 1, provider-signed) or religious (page 2) exemption from Vermont immunization requirements for undergraduate college students.
Medical Immunization Exemption Form (Child Care and Schools) - Spanish
Medical exemption from Vermont's Immunization Rule (18 V.S.A. 1123) for child care and K-12 when a vaccine is contraindicated or may be detrimental to health.
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 (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.
Combined out-of-hospital DNR order and clinician orders for life-sustaining treatment (18 V.S.A. 9708), honored by EMS and facilities.
Consulting physician confirms diagnosis, prognosis and capacity for a patient under Vermont's Patient Choice at End of Life law.
Prescribing physician reports compliance with Vermont's Patient Choice at End of Life law (18 V.S.A. Chapter 113) after writing a prescription.
Prescribing physician reports whether the patient ingested the medication and the circumstances of death.
Application to have a person taken for emergency psychiatric examination, stating the facts showing they are a person in need of treatment (18 V.S.A. §7504).
First certification by a licensed physician that a person subject to an emergency examination application is a person in need of treatment, authorizing admission to a designated hospital for emergency examination (18 V.S.A. §7505).
Psychiatrist's second certification, after the person's admission on an emergency exam, that they are a person in need of treatment, continuing the involuntary hold (18 V.S.A. §7508).
Healthcare professional verifies that the patient-applicant has a debilitating medical condition as defined by Vermont law (not a prescription or recommendation).
Provider report of a condition reportable within 24 hours to the Vermont Department of Health.
Reports a patient started on rabies post-exposure prophylaxis, with exposure and animal details.
Health care provider certification that the applicant meets the definition of a person with a developmental disability (18 V.S.A. § 9302) for a free permanent fishing license.
Physician statement that a licensed hunter is paraplegic or has a permanent severe physical disability and cannot walk 25 feet from a roadway, so a permit to hunt from a motor vehicle off the right of way can be issued.
Physician certification of paraplegia or a permanent, severe physical mobility disability for a free permanent fishing or combination hunting/fishing license.
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.
Vermont's single state form that works as both an out-of-hospital DNR order and clinician orders for life-sustaining treatment under 18 V.S.A. 9708. An MD, DO, PA or APRN completes it through shared decision-making with the patient or agent, and EMS and facilities honor it. The patient keeps the form, and an optional DNR ID bracelet is available from approved vendors.
A licensed physician for general licensing, and a licensed physician, PA or NP for school bus medicals. Sections C to E are for the medical examiner, and Section C covers disabled parking plates. The form is mailed to Vermont DMV, and incomplete forms are returned. Any medical charges are the patient's responsibility. Eye exams go on the separate VS-017, which is void if DMV receives it more than six months after the exam.
A licensed physician designated by the Commissioner who examined the person. DMH requires physicians to complete an online training module and apply for designation before signing first certifications. The Physician's Certificate (1st Cert) goes with the person and the Application for Emergency Exam to the designated hospital, with a copy to the VPCH admissions office. After admission, a psychiatrist at the hospital completes the Second Certificate.
An MD, DO, ND, PA or APRN/NP licensed in Vermont, New Hampshire, Massachusetts or New York, with a bona fide relationship with the patient of at least 3 months. The 3-month rule is waived for terminal illness, cancer, AIDS, hospice and a few other cases. The Healthcare Professional Verification Form verifies a debilitating condition; it is not a prescription. Upload it through the VisualVault provider portal or send it to the program. It must be signed within 6 months of submission.