Molinalogo

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:
February 2021 Cardiovascular Fax
March 2019 January 2020 CGMS Update Fax
February 2020 Home Health PDGM Fax
April 2020 Optum Pre-pay Fax
May 2020 Osteoporosis Medications Fax
June 2020 Home Healthcare Fax
August 2020 Back to School Fax
August 2020 PA Update UDS Fax
September 2020 VaxCare Fax
October 2020 PDL Changes Fax
April 2021 Allergies Fax

*** SCDHHS Forms