| Form Name |
Form Number |
PDF Format |
Word Format |
| Abortion Certification Statements (Rev. 09/05) |
HCF 1161 |
PDF (94 KB) |
|
| Acknowledgment of Receipt of Hysterectomy Information (Rev. 09/05) |
HCF 1160 |
PDF
(31 KB) |
Word (41 KB) |
Adjustment / Reconsideration Request (Rev. 08/05)
Completion Instructions (Rev. 08/05) |
HCF 13046
HCF 13046A |
PDF
(91 KB)
PDF
(26 KB) |
Word (74 KB)
|
| Adult Immunization Record (05/04) |
HCF 1141 |
PDF (48 KB) |
|
| Automated Voice Response System Information Optional Worksheet (08/05) |
HCF 1015 |
PDF (217 KB) |
Word (88 KB) |
| BadgerCare Plus Express Enrollment for Children and
Application Packet for Partners and Providers |
|
PDF (83 KB) |
|
| BadgerCare Plus Express Enrollment for Pregnant Women and Application Packet for Qualified Providers |
|
PDF (392 KB) |
|
| Breast Pump Order (Rev. 09/05) |
HCF 1153 |
PDF
(65 KB) |
Word (33 KB) |
Certification of Emergency For Non-U.S. Citizens (Rev. 08/05)
Completion Instructions (Rev. 08/05) |
HCF 1162
HCF 1162A |
PDF (62 KB)
PDF (24 KB) |
Word (34 KB)
|
| Certification of Need for Elective/Urgent Psychiatric Substance
Abuse Admissions to Hospital Institutions for Mental Disease for
Recipients Under Age 21 (Rev. 08/03) |
HCF 11047 |
PDF
(19 KB) |
Word |
| Certification of Need for Emergency Psychiatric / Substance Abuse
Admissions to Hospital Institutions for Mental Disease for Recipients
Under Age 21 and in Cases of Medicaid Determination After Admission (Rev.
08/03) |
HCF 11048 |
PDF (21 KB) |
Word |
Certification of Need for Specialized Medical Vehicle Transportation
Completion Instructions (11/06) |
HCF 1197
HCF 1197A |
PDF
(71 KB)
PDF
(17 KB) |
Word
(41 KB) |
| Certification of Public Expenditures |
HCF 1003 |
PDF (109 KB) |
|
Claim Refund (Rev. 08/05)
Completion Instructions (Rev. 08/05) |
HCF 13066
HCF 13066A |
PDF
(223 KB)
PDF
(22 KB) |
Word (55 KB)
|
| Declaration of Supervision for Nonbilling Providers (01/08) |
HCF 1182 |
PDF
(65 KB) |
|
| Drug Addition/Correction Request Form |
PA02076.RH |
PDF (127 KB) |
|
Drug Claims — Compound Drug Claim (Rev. 06/03)
Completion Instructions (Rev. 06/03) |
HCF 13073
HCF 13073A |
PDF
(115 KB)
PDF
(31KB) |
|
Drug Claims — Noncompound Drug Claim (Rev. 06/03)
Completion Instructions (Rev. 06/03) |
HCF 13072
HCF 13072A |
PDF
(82 KB)
PDF
(30 KB) |
|
Federally Qualified Health Center Cost Report Forms (Rev. 03/06)
Completion Instructions (Rev. 03/06) |
HCF 11129B-H
HCF 11129A |
Excel (131 KB)
PDF (38 KB) |
|
Federally Qualified Health Center Interim Report (Rev. 03/06)
Completion Instructions (Rev. 03/06) |
HCF 11130
HCF 11130A |
Excel (28 KB)
PDF (16 KB) |
|
| HealthCheck Forms |
|
|
|
HealthCheck Adolescent Review (Rev. 12/03) |
HCF 1062 |
PDF (12 KB) |
|
HealthCheck Family History (Rev. 11/03) |
HCF 1063 |
PDF (11 KB) |
|
HealthCheck Spanish Version (Rev. 11/03) |
HCF 1063S |
PDF (11 KB) |
|
HealthCheck Individual Health History |
HCF 1002 |
PDF (276 KB) |
|
|
HealthCheck Individual Health History — Hmong |
HCF 1002H |
PDF (50 KB) |
|
HealthCheck Individual Health History — Spanish |
HCF 1002S |
PDF (452 KB) |
|
HealthCheck Infant's Food Record (Birth to 12 Months of
Age) (Rev. 12/03) |
HCF 1066 |
PDF (10 KB) |
|
HealthCheck Child's Food Record (1-12 Years of Age) (Rev. 08/01) |
HCF 1066A |
PDF (8 KB) |
|
HealthCheck Child's Food Record / 1-12 Years of Age (Spanish) (Rev. 08/01) |
HCF 1066AS |
PDF (10 KB) |
|
HealthCheck Adolescent's Food Record (13 to 20 Years of Age) (Rev. 12/03) |
HCF 1066B |
PDF (7 KB) |
|
HealthCheck Adolescent's Food Record (13 to 20 Years of Age) (Rev.
12/03) |
HCF 1066BS |
PDF (10 KB) |
|
HealthCheck Your Child's Speech and Hearing (Rev. 12/03) |
HCF 1067 |
PDF (20 KB) |
|
General Pediatric Clinic / 3 - 4 Week Visit (Rev. 09/01) |
HCF 1068A |
PDF (25 KB) |
|
General Pediatric Clinic / 6 - 8 Week Visit (Rev. 09/01) |
HCF 1068B |
PDF (25 KB) |
|
General Pediatric Clinic / 4 Month Visit (Rev. 09/01) |
HCF 1068C |
PDF (24 KB) |
|
General Pediatric Clinic / 6 Month Visit (Rev. 09/01) |
HCF 1068D |
PDF (25 KB) |
|
General Pediatric Clinic 9 Month Visit (Rev. 09/01) |
HCF 1068E |
PDF (25 KB) |
|
General Pediatric Clinic 12 Month Visit (Rev. 09/01) |
HCF 1068F |
PDF (24 KB) |
|
General Pediatric Clinic 15 Month Visit (Rev. 09/01) |
HCF 1068G |
PDF (23 KB) |
|
General Pediatric Clinic 18 Month Visit (Rev. 09/01) |
HCF 1068H |
PDF (24 KB) |
|
General Pediatric Clinic 24 Month Visit (Rev. 09/01) |
HCF 1068I |
PDF (23 KB) |
|
General Pediatric Clinic Pre-school Visit (Rev. 09/01) |
HCF 1068J |
PDF (22 KB) |
|
General Pediatric Clinic Elementary School Visit (Rev. 09/01) |
HCF 1068K |
PDF (21 KB) |
|
General Pediatric Clinic Teenager Visit (Rev. 09/01) |
HCF 1068L |
PDF (21 KB) |
|
Confidential Health Survey (Rev. 09/01) |
HCF 1068M |
PDF (15 KB) |
|
HealthCheck Age Specific Documentation Confidential Health
Survey (Spanish) (Rev. 09/03) |
HCF 1068MS |
PDF (16 KB) |
|
HealthCheck Poster
Order HealthCheck Posters |
PHC 1042 |
PDF (84 KB) |
|
| Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge
(Rev. 08/05) |
HCF 1010 |
PDF (78 KB) |
Word (33 KB) |
| In-State Emergency Provider Data Sheet (Rev. 08/05) |
HCF 11002 |
PDF
(367 KB) |
Word (52 KB) |
| License Application for Nursing Home, Facility for Developmentally
Disabled, Institute for Mental Disease |
HCF 1022A-E |
Excel (80 KB) |
|
| Managed Care Program Provider Appeal (Rev. 08/05) |
HCF 12022 |
PDF (83 KB) |
Word (41 KB) |
| Maximum Allowable Fee Schedule Order Form (Rev. 01/04) |
HCF 1005 |
PDF (116 KB) |
Word |
| Medical Professional Statement in Support of Request for Variance of
60-Day Supervisory Visit Requirement (10/01) |
HCF 1174 |
PDF
(112 KB) |
|
| Medicare Part D Attestation (01/06) |
HCF 1094 |
PDF (94 KB) |
Word (49 KB) |
Mental Health Day Treatment Functional Assessment (Rev. 08/05)
Completion Instructions |
HCF 11090
HCF 11090A |
PDF (352 KB)
PDF (23 KB) |
Word (176 KB)
|
| Model Multi-Agency Treatment Plan (01/07) |
HCF 11106 |
PDF (303 KB) |
Word (103 KB) |
| Model Plan: In-Home Mental Health / Substance Abuse Treatment Services
(01/07) |
HCF 11105 |
PDF (251 KB) |
Word (93 KB) |
| National Provider Identifier Collection (03/08) |
HCF 13505 |
PDF (103 KB) |
Word (58 KB) |
| Newborn Report (Rev. 02/03) |
HCF 1165 |
PDF
(30 KB) |
Word (41 KB) |
| Notification of Medicaid Hospice Benefit Election (Rev. 08/05) |
HCF 1008 |
PDF (134 KB) |
Word (75 KB) |
| Optional School-Based Services Activity Log Medication Administration |
HCF 1199 |
PDF (66 KB)
(for printing) |
Word (70 KB)
(fillable) |
| Optional School-Based Services Activity Log Nursing / Therapy Medical
Services |
HCF 1198 |
PDF (69 KB)
(for printing) |
Word (59 KB)
(fillable) |
| Other Coverage Discrepancy Report (Rev. 08/05) |
HCF 1159 |
PDF
(58 KB) |
Word (55 KB) |
| Out-of-State Provider Data Sheet (06/07) |
HCF 11001 |
PDF
(368 KB) |
Word (53 KB) |
Optional Outpatient Mental Health Assessment and Treatment /
Recovery Plan (01/07)
Completion Instructions |
HCF 11103
HCF 11103A |
PDF (376 KB)
PDF (20 KB) |
Word (106 KB)
|
Personal Care Addendum (05/07)
Completion Instructions (05/07) |
HCF 11136
HCF 11136A |
PDF (549 KB)
PDF (19 KB) |
Word (151 KB) |
| Personal Care Prior Authorization Provider
Acknowledgement (05/07) |
HCF 11134 |
PDF (37 KB) |
Word (38 KB) |
Personal Care Screening Tool (PCST) (05/07)
Completion Instructions (05/07) |
HCF 11133
HCF 11133A |
PDF (65 KB)
PDF (110 KB) |
|
Personal Care Worker Weekly Record of Care
(10/00)
Completion Instructions |
HCF 1151 |
PDF
(1000 KB)
PDF
(97 KB) |
|
Personal Care Worker Daily Record of Care (10/00)
Completion Instructions |
HCF 1152 |
PDF
(424 KB)
PDF
(71 KB) |
|
Pharmacy Special Handling Request (Rev. 6/06)
Completion Instructions (06/06) |
HCF 13074
HCF 13074A |
PDF (162 KB)
PDF (18 KB) |
Word (37 KB) |
| Physician Certification / Recertification of
Terminal Illness (Rev. 08/05) |
HCF 1011 |
PDF (70 KB) |
Word (35 KB) |
Prenatal Care Coordination Program Pregnancy Questionnaire (Rev. 02/06)
Completion Instructions (Rev. 02/06)
Hmong Questionnaire
Spanish Questionnaire
|
HCF 1105
HCF 1105A
HCF 1105H
HCF 1105S
|
PDF
(1453 KB)
PDF (242 KB)
PDF (74 KB)
PDF (198 KB) |
Word (134 KB)
|
Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/AMHDTA)
(Rev. 06/03)
Completion Instructions (Rev. 06/03) |
HCF 11038
HCF 11038A |
PDF
(51 KB)
PDF (18 KB) |
Word |
Prior Authorization Amendment Request (05/07)
Completion Instructions (05/07) |
HCF 11042
HCF 11042A |
PDF
(173 KB)
PDF (15 KB) |
Word (46 KB)
|
| Prior Authorization / Birth to 3 Attachment (PA/B3) (Rev. 01/03) |
HCF 11011 |
PDF
(95 KB) |
Word |
Prior Authorization / Brand Medically Necessary
Attachment (PA/BMNA) (03/05)
Completion Instructions (03/05) |
HCF 11083
HCF 11083A |
PDF (225 KB)
PDF (71 KB) |
|
Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA)
(Rev. 03/06)
Completion Instructions (Rev. 03/06) |
HCF 11040
HCF 11040A |
PDF
(280 KB)
PDF
(173 KB) |
Word
|
Prior Authorization / Chiropractic Attachment (PA/CA) (Rev. 02/04)
Completion Instructions (Rev. 02/04) |
HCF 11029
HCF 11029A |
PDF
(92 KB)
PDF
(70 KB) |
Word
|
Prior Authorization Dental Attachment 1 (PA/DA1) (11/06)
Completion Instructions (11/06) |
HCF 11010
HCF 11010A |
PDF
(372 KB)
PDF
(19 KB) |
Word (149 KB)
|
| Prior Authorization Dental Attachment 2 (PA/DA2) Oral Surgery,
Orthodontic, and Fixed Prosthetic Services (11/06) |
HCF 11014 |
PDF
(214 KB) |
Word (81 KB) |
Prior Authorization / Drug Attachment (PA/DGA) (Rev. 06/03)
Completion Instructions (Rev. 06/03) |
HCF 11049
HCF 11049A |
PDF
(55 KB)
PDF
(21 KB) |
Word
|
Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA)
(Rev. 06/03)
Completion Instructions (Rev. 06/03) |
HCF 11030
HCF 11030A |
PDF
(146 KB)
PDF
(23 KB) |
Word |
Prior Authorization / Environmental Lead Inspection (PA/ELI)
Worksheet (Rev. 09/03)
Completion Instructions (Rev. 09/03) |
HCF 11062
HCF 11062A |
PDF (145 KB)
PDF (72 KB) |
|
Prior Authorization / Enteral Nutrition Product
Attachment (PA/ENPA) (Rev. 07/03)
Completion Instructions (Rev. 07/04) |
HCF 11054
HCF 11054A |
PDF (128 KB)
PDF (83 KB) |
Word |
| Prior Authorization Fax Cover Sheet (Rev. 08/05) |
HCF 1176 |
PDF (74 KB) |
Word (35 KB) |
Prior Authorization / Mental Health and / or Substance Abuse Evaluation Attachment (PA/EA) (01/07)
Completion Instructions (01/07) |
HCF 11033
HCF 11033A |
PDF
(42 KB)
PDF (28 KB) |
Word (45 KB)
|
Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA)
(06/05)
Completion Instructions |
HCF 11088
HCF 11088A |
PDF (71 KB)
PDF (95 KB) |
Word (47 KB)
|
Prior Authorization / Home Care Attachment (PA/HCA)
(Rev. 03/06)
Completion Instructions (Rev. 03/06) |
HCF 11096
HCF 11096A |
PDF (374 KB)
PDF (47 KB) |
Word (97 KB)
|
Prior Authorization / Home Health Therapy Attachment (PA/HHTA) (Rev.
06/03)
Completion Instructions (Rev. 06/03) |
HCF 11044
HCF 11044A |
PDF
(102 KB)
PDF
(71 KB) |
Word
|
Prior Authorization / Intensive In-Home Treatment Attachment (PA/ITA)
(01/07)
Completion Instructions (01/07) |
HCF 11036
HCF 11036A |
PDF
(353 KB)
PDF (103 KB) |
Word (85 KB) |
Prior Authorization / "J" Code Attachment (PA/JCA) (Rev.
06/03)
Completion Instructions (Rev. 06/03) |
HCF 11034
HCF 11034A |
PDF
(96 KB)
PDF
(86 KB) |
Word (46 KB)
|
Prior Authorization / Oxygen Attachment (PA/OA) (Rev. 05/05)
Completion Instructions (Rev. 05/05) |
HCF 11066
HCF 11066A |
PDF (200 KB)
PDF (76 KB) |
Word
|
Prior Authorization Physician Attachment (PA/PA) (Rev. 1/03)
Completion Instructions (Rev. 1/03) |
HCF 11016
HCF 11016A |
PDF
(371 KB)
PDF
(71 KB) |
Word (40 KB)
|
Prior Authorization / Physician Otological Report (PA/POR) (Rev. 06/03)
Completion Instructions (Rev. 06/03) |
HCF 11019
HCF 11019A |
PDF
(93 KB)
PDF
(86 KB) |
Word
|
Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request
(12/06)
Completion Instructions (12/06)
|
HCF 11075
HCF 11075A
|
PDF (205 KB)
PDF (31 KB)
|
Word (73 KB) |
Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell
Adhesion Molecule (CAM) Antagonist Drugs For Ankylosing Spondylitis (11/07)
Completion Instructions (11/07) |
HCF 11304
HCF 11304A |
PDF (323 KB)
PDF (22 KB) |
Word (63 KB)
|
Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell
Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease (11/07)
Completion Instructions (11/07) |
HCF 11305
HCF 11305A |
PDF (244 KB)
PDF (22 KB) |
Word (64 KB) |
Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell
Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis (11/07)
Completion Instructions (11/07) |
HCF 11306
HCF 11306A |
PDF (353 KB)
PDF (22 KB) |
Word (60 KB) |
Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell
Adhesion Molecule (CAM) Antagonist Drugs for Psoriatic Arthritis (11/07)
Completion Instructions (11/07) |
HCF 11307
HCF 11307A |
PDF (125 KB)
PDF (22 KB) |
Word (66 KB) |
Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell
Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (11/07)
Completion Instructions (11/07) |
HCF 11308
HCF 11308A |
PDF (186 KB)
PDF (22 KB) |
Word (67 KB) |
Prior Authorization / Preferred Drug List (PA/PDL) for Elidel® and Protopic® (03/08)
Completion Instructions (03/08) |
HCF 11303
HCF 11303A |
PDF (108 KB)
PDF (95 KB) |
Word (79 KB) |
Prior Authorization / Preferred Drug List (PA/PDL) for Exubera (03/07)
Completion Instructions (03/07) |
HCF 11294
HCF 11294A |
PDF (308 KB)
PDF (24 KB) |
Word (102 KB)
|
Prior Authorization / Preferred Drug List (PA/PDL)
for Growth Hormone Drugs (03/07)
Completion Instructions (03/07) |
HCF 11092
HCF 11092A |
PDF (434 KB)
PDF (25 KB) |
Word (82 KB)
|
Prior Authorization / Preferred Drug List (PA/PDL) for Hypoglycemics for
Adjunct Therapy (06/07)
Completion Instructions (06/07) |
HCF 11179
HCF 11179A |
PDF (385 KB)
PDF (35 KB) |
Word (103 KB) |
Prior Authorization / Preferred Drug List (PA/PDL) for Lamisil (09/06)
Completion Instructions (09/06) |
HCF 11180
HCF 11180A |
PDF (174 KB)
PDF (36 KB) |
Word (74 KB) |
Prior Authorization / Preferred Drug List (PA/PDL) for Non-Steroidal
Anti-Inflammatory Drugs (NSAIDs), Including Cyclo-oxygenase Inhibitors (09/07)
Completion Instructions (09/07)
|
HCF 11077
HCF 11077A
|
PDF (101 KB)
PDF (23 KB) |
Word (76 KB)
|
Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump
Inhibitor (PPI) Drugs (03/08)
Completion Instructions (03/08) |
HCF 11078
HCF 11078A |
PDF (76 KB)
PDF (94 KB) |
Word (69 KB) |
Prior Authorization / Preferred Drug List (PA/PDL) for
Stimulants and Related Agents (11/07)
Completion Instructions (11/07) |
HCF 11097
HCF 11097A |
PDF (222 KB)
PDF (24 KB) |
Word (108 KB) |
Prior Authorization / Psychotherapy Attachment (PA/PSYA) (01/07)
Completion Instructions (01/07) |
HCF 11031
HCF 11031A |
PDF
(28 KB)
PDF (19 KB) |
Word (53 KB)
|
| Prior Authorization / Residential Care Center Treatment Services
Forms |
|
|
|
Prior Authorization Request Form (PA/RF) Completion Instructions for
Residential Care Center Treatment Services (Rev. 10/04) |
HCF 11076 |
PDF (60 KB) |
|
Prior Authorization / Residential Care Center Treatment Services
Attachment (PA/RCCA) for initial admission and unplanned readmission within
90 days of discharge from RCC (Rev. 09/06) |
HCF 11076A |
PDF (23 KB) |
Word (60 KB) |
Prior Authorization / Residential Care Center Treatment Services
Attachment (PA/RCCA) for continuing services (Rev. 10/04) |
HCF 11076B |
PDF (12 KB) |
|
Prior Authorization / Residential Care Center Treatment Attachment (PA/RCCA)
Completion Instructions for initial admissions, unplanned readmissions, and
for continuing services (Rev. 09/06) |
HCF 11076C |
PDF (21 KB) |
|
Prior Authorization / Spell of Illness Attachment (PA/SOIA) (Rev. 06/03)
Completion Instructions (Rev. 06/03) |
HCF 11039
HCF 11039A |
PDF
(50 KB)
PDF
(75 KB) |
Word
|
Prior Authorization / Substance Abuse Attachment (PA/SAA) (Rev. 06/03)
Completion Instructions (Rev. 06/03) |
HCF 11032
HCF 11032A |
PDF
(272 KB)
PDF
(75 KB) |
Word
|
Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA)
(Rev. 06/03)
Completion Instructions (Rev. 06/03) |
HCF 11037
HCF 11037A |
PDF
(93 KB)
PDF
(109 KB) |
Word
|
Prior Authorization / Therapy Attachment (PA/TA) (Rev. 06/03)
Completion Instructions (Rev. 06/03) |
HCF 11008
HCF 11008A |
PDF
(161 KB)
PDF
(51 KB) |
Word
|
Prior Authorization / Vision Services Attachment (PA/VA) (Rev. 06/03)
Completion Instructions (Rev. 06/03) |
HCF 11051
HCF 11051A |
PDF
(89 KB)
PDF
(60 KB) |
Word
|
| Private Duty Nursing Prior
Authorization Acknowledgment (Rev. 09/05) |
HCF 11041 |
PDF
(76 KB) |
Word (32 KB) |
| Probate Claims Notice (Rev. 11/02) |
HCF 13033 |
PDF
(27 KB) |
|
Provider Change of Address or Status (Rev. 08/05)
Completion Instructions (Rev. 08/05) |
HCF 1181
HCF 1181A |
PDF (113 KB)
PDF (67 KB) |
Word (51 KB)
|
| Provider Handbook Order Form (08/07) |
HCF 1179 |
|
Word (116 KB) |
| Provider Suggestion Form (Rev. 08/05) |
HCF 1016 |
PDF (61 KB) |
Word (38 KB) |
| Recipient Election of Medicaid Hospice Benefit (Rev. 08/05) |
HCF 1009 |
PDF (76 KB) |
Word (32 KB) |
| Recipient Request for Variance of 60-Day Supervisory Visit Requirement
(10/01) |
HCF 1175 |
PDF
(101 KB) |
|
| Record of Actual Daily Oxygen Use (Rev. 05/05) |
HCF 11067 |
PDF (226 KB) |
Word |
| Registration to Receive Report of Medicaid-Eligible Students for
School-Based Services Providers (12/05) |
HCF 1018 |
PDF (107 KB) |
Word (39 KB) |
| Request for a Waiver to Wisconsin Medicaid Prescription Requirements
Under the School-Based Services Benefit (01/08) |
HCF 1134 |
PDF (76 KB) |
Word (37 KB) |
| Request for Discretionary Waiver of Qualifications for a Registered
Nurse Supervisor (04/04) |
HCF 1142 |
PDF (177 KB) |
|
Request for Nursing Home Care Determination
Completion Instructions |
HCF 1020
HCF 1020A |
PDF (66 KB)
PDF (15 KB) |
Word (42 KB) |
| Request for Unique Suffix Number for Acquired Immune Deficiency
Syndrome, Ventilator-Dependent, or Brain Injury Cases — Inpatient
Hospital (04/02) |
HCF 1168 |
PDF
(50 KB) |
|
| Request for Waiver of Physical Therapist Assistant and Occupational
Therapy Assistant Supervision Requirements (07/00) |
HCF 1149 |
PDF (80 KB) |
Word (37 KB) |
| Rural Health Clinic Forms |
|
|
|
Cost Report for Independent and Provider-Based
(Affiliated Hospital Having More Than 50 Beds) Rural Health Clinics
(Rev. 02/05)
Completion Instructions (Rev. 02/05) |
HCF 11079
HCF 11079A |
Excel (31 KB)
PDF (67 KB) |
|
Cost Report for Provider-Based Rural Health Clinics
(Affiliated Hospital Having 50 or Fewer Beds)
(Rev. 02/05)
Completion Instructions (Rev. 02/05) |
HCF 11080
HCF 11080A |
Excel (56 KB)
PDF (56 KB) |
|
Rural Health Clinic Commercial Insurance-Primary/Medicaid-Secondary
Encounters Submitted to Medicaid HMOs (05/03)
Completion Instructions (05/03) |
HCF 11025
HCF 11025A |
PDF
(375 KB)
PDF
(11 KB) |
|
Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid
HMOs (05/03)
Completion Instructions (05/03) |
HCF 11026
HCF 11026A |
PDF
(269 KB)
PDF
(10KB) |
|
Rural Health Clinic Provider Staff Encounters Form
(Rev. 02/05) |
HCF 11081 |
Excel (18 KB) |
|
Rural Health Clinic Quarterly Cost Report (05/03)
Completion Instructions (05/03) |
HCF 11027
HCF 11027A |
PDF
(26 KB)
PDF
(10 KB) |
|
Rural Health Clinic Statistical Data (01/08) |
HCF 11022 |
PDF
(109 KB) |
Word (91 KB) |
Rural Health Clinic Reclassifications and Adjustment of Trial Balance
Expenses (02/05)
Completion Instructions (Rev. 02/05) |
HCF 11023
HCF 11023A |
Excel
(55 KB)
PDF
(52 KB) |
|
School-Based Services Cost Report (07/07)
Completion Instructions (12/07)
Sample —
Completed SBS Cost Report (Excel, 59 KB)
Compensation Data Worksheet (Excel, 17 KB) |
HCF 1538
HCF 1538A |
Excel (59 KB)
PDF (68 KB) |
|
School-Based Services Matching Expenditures (12/04)
Completion Instructions (12/04) |
HCF 1004
HCF 1004A |
PDF (313 KB)
PDF (81 KB) |
|
| Screening Recommendations for Pediatric Eye Problems |
PHC 1033 |
PDF (12 KB) |
|
| Specialized Medical Vehicle Driver Information Chart (01/08) |
HCF 1301 |
PDF
(481 KB) |
Word (77 KB) |
| Specialized Medical Vehicle Information Chart (01/08) |
HCF 1300 |
PDF (96 KB) |
Word (57 KB) |
Specialized Medical Vehicle Transportation Trip Ticket / Medical Care
Verification (nonfillable) (11/06)
Completion Instructions |
HCF 1050
HCF 1050A |
PDF
(20 KB)
PDF
(32 KB) |
|
| STAT-PA Pharmacy Drug Worksheet Instructions for the following three
worksheets: |
HCF 11055 |
PDF (26 KB) |
|
STAT-PA Drug Worksheet for Alpha-1 Proteinase Inhibitor |
HCF 11056 |
PDF (168 KB) |
|
STAT-PA Drug Worksheet for C-III and C-IV Stimulants and
Anti-Obesity
Drugs |
HCF 11061 |
PDF (197 KB) |
|
STAT-PA Orthopedic Shoes Worksheet
Completion Instructions |
HCF 11052
HCF 11052A |
PDF
(256 KB)
PDF (88 KB) |
|
STAT-PA Specialized Medical Vehicle
Worksheet
Completion Instructions |
HCF 11053
HCF 11053A |
PDF (39 KB)
PDF (19 KB) |
|
Sterilization Informed Consent Form
Completion Instructions, and Sample Form
Spanish Consent Form |
HCF 1164
HCF 1164A
HCF 1164S
|
PDF
(43 KB)
PDF (23 KB)
PDF (40 KB)
|
Word
(36 KB)
Word (60 KB)
|
| Timely Filing Appeals Request (Rev. 08/05) |
HCF 13047 |
PDF
(144 KB) |
Word (44 KB) |
| Urgent Care Dental In-State Emergency Provider Data Sheet |
HCF 11013 |
PDF
(101 KB) |
Word |
Verbal Orders for Recertification: Home Health
Agency Request for Variance of Physician Signature
Completion Instructions |
HCF 1017
HCF 1017A |
PDF (94 KB)
PDF (11 KB) |
Word (38 KB) |
Weekly Driver's Inspection Report
Completion Instructions |
HCF 1302
HCF 1302A |
PDF
(125 KB)
PDF
(7 KB) |
|
| Written Correspondence Inquiry (Rev. 08/05) |
HCF 1170 |
PDF
(227 KB) |
Word (62 KB) |
