Frequently Used Forms
Consent Forms
- Hysterectomy Consent & Patient Form (hca.wa.gov)
- Member Consent/Appeal Form
- Member Education Form
- Sterilization Form (hhs.gov)
Credentialing/Contracting
- Contract Request Form
- Add Provider Request Form (Mini Application)
- Health Delivery Organization (HDO) Form – Facilities
- CMS Ownership Control and Disclosure Form
- W-9 (irs.gov)
Opioid Policy
To access the opioid policy and opioid attestation form, please visit the Washington Drug Formulary page.
Other
- A-19 State of Washington Form
- Application for Health Care Coverage (hca.wa.gov)
- Dismissal Letter
- Exception to Rule Request
- New Supplier Form
- Notification Form for Change in WISe Services
- PCP Change Request Form
- PCP Change Request Form – Spanish
- Provider Bariatric Program Flyer
- Provider Critical Incident Referral Form
- Provider Dispute Resolution Request Form
- Provider Early Reversal Permission Form
Prior Authorization Request Forms
PharmacyFor pharmacy prior authorization forms, please visit the Washington Drug Formulary page.
Pre-Service- Applied Behavior Analysis (ABA) Therapy Prior Authorization Form
- Applied Behavior Analysis (ABA) Level of Support Requirement Form
- Applied Behavior Analysis (ABA) Order Form
- Behavioral Health Admission Notification/Authorization Request Form
- Bariatric Surgery Criteria Pre-Surgical Assessment Form
- Inpatient Rehab, Skilled Nursing Facility, and Long Term Acute Care Request Form
- Medicaid Attestation Form on the Appropriateness of the Qualified Clinical Trial (hca.wa.gov)
- Prior Authorization Pre-Service Guide and Form Medicaid
- Private Duty Nursing Prior Authorization Request Form
Provider Changes
Reference/Criteria Guide
- Applied Behavior Analysis (ABA) Provider Utilization Management Guide
- ABA Treatment Prior Authorization FAQs
- BH Provider Prior Authorization Reference Guide
- BMI Index-for-Age Percentile Charts for Children (cdc.gov)
- Molina Healthcare of Washington, Oncology Pathway Solutions FAQs
- Process for Skilled Nursing Facility (SNF) Requests
- Initial Authorization Process - Skilled Nursing Facility
- Washington Health Care Authority Clinical Trials FAQs
- Medicaid Membership Roster Clean-up FAQ, Criteria and Processes
Referral Forms
Member Rewards Program
CY23-24 Flu Incentive Flyers
Well-Care Visit Back to School Flyers
Provider Forms
Member Forms
- Program Information - Flyer (English)
- 30-Month Well-Child Visits (English)
- Childhood Immunizations (English)
- 3-11 Year Well-Care Visits (English)
- ADHD Medication Follow-Up Visit (English)
- Immunizations for Adolescents (English)
- 12-21 Year Well-Care Visits (English)
- Chlamydia Screening (English)
- Prenatal Visit (English)
- Postpartum Visit (English)
- Breast Cancer Screening (English)
- Cervical Cancer Screening (English)
- Diabetes Screening (English)
- Adolescent & Adult Combined Form (English)
- Program Information - Flyer (Spanish)
- 30-Month Well-Child Visits (Spanish)
- Childhood Immunizations (Spanish)
- 3-11 Year Well-Care Visits (Spanish)
- ADHD Medication Follow-Up Visit (Spanish)
- Immunizations for Adolescents (Spanish)
- 12-21 Year Well-Care Visits (Spanish)
- Chlamydia Screening (Spanish)
- Prenatal Visit (Spanish)
- Postpartum Visit (Spanish)
- Breast Cancer Screening (Spanish)
- Cervical Cancer Screening (Spanish)
- Diabetes Screening (Spanish)
- Adolescent & Adult Combined Form (Spanish)
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