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
Referral Forms
Amazon Member Reward Program
Provider FormsMember Forms
- Amazon Rewards – Program Information
- Amazon Rewards – 30-Month Well-Child Visits
- Amazon Rewards – Childhood Immunizations
- Amazon Rewards – 3-11 Year Well-Care Visits
- Amazon Rewards – ADHD Medication Follow-Up Visit
- Amazon Rewards – Immunizations for Adolescents
- Amazon Rewards – 12-21 Year Well-Care Visits
- Amazon Rewards – Chlamydia Screening
- Amazon Rewards – Prenatal Visit
- Amazon Rewards – Postpartum Visit
- Amazon Rewards – Breast Cancer Screening
- Amazon Rewards – Cervical Cancer Screening
- Amazon Rewards – Diabetes Screening
- Amazon Rewards – Adolescent & Adult Combined Form
- Amazon Rewards – Program Information (Spanish)
- Amazon Rewards – 30-Month Well-Child Visits (Spanish)
- Amazon Rewards – Childhood Immunizations (Spanish)
- Amazon Rewards – 3-11 Year Well-Care Visits (Spanish)
- Amazon Rewards – ADHD Medication Follow-Up Visit (Spanish)
- Amazon Rewards – Immunizations for Adolescents (Spanish)
- Amazon Rewards – 12-21 Year Well-Care Visits (Spanish)
- Amazon Rewards – Chlamydia Screening (Spanish)
- Amazon Rewards – Prenatal Visit (Spanish)
- Amazon Rewards – Postpartum Visit (Spanish)
- Amazon Rewards – Breast Cancer Screening (Spanish)
- Amazon Rewards – Cervical Cancer Screening (Spanish)
- Amazon Rewards – Diabetes Screening (Spanish)
- Amazon Rewards – Adolescent & Adult Combined Form (Spanish)
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