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:
Health Education Referral Form
Disease Management/Case Management Referral Form
Delivery Notification Form
Neonatal Transfer Form
Pregnancy Notification Report
Abortion Statement
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SBIRT Integrated Screening Tool
Surgical Justification Review For Hysterectomy
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Prior Authorization Forms:
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 ***
MCO Universal 17P Makena Prior Authorization Form ***
Provider Network/Credentialing Forms:
Credentialing Checklist
Practice Demographics Form
Provider Change Form
Primary Care Provider Change Request Form
Contract Request Form
Facility HDO Form
Provider Load Roster
SCDHHS Ownership Form ***
Non Medicaid Enrolled Ownership Disclosure Form
Claims Forms:
Provider Recovery Reversal Permission Form
Provider Resources:
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
September 2021 Outpatient Definitive Drug Testing Fax
October 2021 Credentialing Changes Provider Fax
October 2021 Flu Fax
November 2021 Well Visit Incentive Reminder Fax
December 2021 Potential ID Card Delay Fax
January 2022 Blank Check Issue Provider Fax
February 2022 Well Visit Provider Incentive Fax