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:
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
February 2021 Cardiovascular Fax
April 2021 Allergies Fax
April 2021 Medical Records Fax
May 2021 Osteoporosis Fax
May 2021 Code Add Back Fax
May 2021 NCQA Newsletter Fax
June 2021 POD Data Verification Fax

July 2021 New Fax For Physician Administered Medication Requests

July 2021 Behavioral Health Fax Number Changes

August 2021 Provider Satisfaction Survey Fax

August 2021 Provider Partial Denials Fax

September 2021 Healthy Start Fax

September 2021 Updating Provider Information Fax

*** SCDHHS Forms