Frequently Used Forms
To access additional forms, including the latest copy of the Consent for Sterilization Form, please visit the SCDHHS Provider Manual Forms section: https://www.scdhhs.gov/internet/pdf/manuals/Physicians/Forms.pdf
Healthcare Services Forms:
Universal Makena-17 P State Form ***
Health Education Referral Form
Disease Management/Case Management Referral Form
Delivery Notification Form
Neonatal Transfer Form
Pregnancy Notification Report
Abortion Statement ***
SBIRT Integrated Screening Tool
Surgical Justification Review For Hysterectomy ***
Prior Authorization Forms:
New Online Authorization Lookup
Universal Prior Authorization Form BabyNet
BH Prior Authorization-Outpatient Treatment-Higher Level of Care Form
Prior Authorization Request Form
Prior Authorization Medications Form
Universal Synagis Prior Authorization Form
Provider Network/Credentialing Forms:
Credentialing Checklist ***
Practice Demographics Form
Provider Change Form
Primary Care Provider Change Request Form
Contract Request Form
October 2020 Provider Satisfaction Survey
Claims Forms:
Provider Recovery Reversal Permission Form
Provider Resources:
Home Health-PDGM FAQ
Transportation Brokers Grid
February 2020 Home Health PDGM Fax
May 2020 Osteoporosis Medications Fax
August 2020 Back to School Fax
*** SCDHHS Forms