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

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

*** SCDHHS Forms