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Medicaid Forms

Below is a list of all Medicaid forms. 

When you are searching for a document, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) DMS English 07/2012 PDF No
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA) DMS English 10/2015 PDF No
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA) DMS English 10/2015 Word No
F-11039A Prior Authorization / Spell of Illness Attachment (PA/SOIA): Completion Instructions DMS English 10/2015 PDF No
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) DMS English 07/2012 Word No
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) DMS English 07/2012 PDF No
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) DMS English 07/2012 Word No
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) DMS English 07/2012 PDF No
F-11037A Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA): Completion Instructions DMS English 07/2012 PDF No
F-11008 Prior Authorization / Therapy Attachment (PA/TA) DMS English 08/2017 PDF No
F-11008 Prior Authorization / Therapy Attachment (PA/TA) DMS English 08/2017 Word No
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS English 10/2020 Word No
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS English 10/2020 PDF No
F-11051A Prior Authorization / Vision Services Attachment (PA/VA), Instructions DMS English 10/2020 PDF No
F-11042 Prior Authorization Amendment Request DMS English 07/2012 PDF No
F-11042 Prior Authorization Amendment Request DMS English 07/2012 Word No
F-11042A Prior Authorization Amendment Request Completion Instructions DMS English 07/2012 PDF No
F-11035 Prior Authorization Dental Request Form (PA/DRF) DMS English 06/2024 PDF No
F-11035 Prior Authorization Dental Request Form (PA/DRF) DMS English 06/2024 Word No
F-11035A Prior Authorization Dental Request Form (PA/DRF) Instructions DMS English 06/2024 PDF No
F-00163 Prior Authorization Drug Attachment for Anti-Obesity Drugs DMS English 07/2024 Word No
F-00163 Prior Authorization Drug Attachment for Anti-Obesity Drugs DMS English 07/2024 PDF No
F-00163A Prior Authorization Drug Attachment for Anti-Obesity Drugs Instructions DMS English 07/2024 PDF No
F-00194 Prior Authorization Drug Attachment for Antiemetics, Cannabinoids DMS English 07/2021 Word No
F-00194 Prior Authorization Drug Attachment for Antiemetics, Cannabinoids DMS English 07/2021 PDF No
F-00194 Prior Authorization Drug Attachment for Antiemetics, Cannabinoids, Instructions DMS English 07/2021 PDF No
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger DMS English 01/2018 PDF No
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger DMS English 01/2018 Word No
F-01952 Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA DMS English 01/2022 PDF No
F-01952 Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA DMS English 01/2022 Word No
F-01952A Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA, Instructions DMS English 01/2022 PDF No
F-11304 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis DMS English 05/2023 PDF No
F-11304 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis DMS English 05/2023 Word No
F-11304A Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis Instructions DMS English 05/2023 PDF No
F-01950 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease and Ulcerative Colitis DMS English 05/2023 PDF No
F-01950 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease and Ulcerative Colitis DMS English 05/2023 Word No
F-01950A Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease and Ulcerative Colitis Instructions DMS English 05/2023 PDF No
F-03174 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa DMS English 07/2023 PDF No
F-03174 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa DMS English 07/2023 Word No
F-03174A Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa, Instructions DMS English 07/2023 PDF No
F-11306 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis DMS English 05/2023 PDF No
F-11306 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis DMS English 05/2023 Word No
F-11306A Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis Instructions DMS English 05/2023 PDF No
F-01951 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis DMS English 05/2023 PDF No
F-01951 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis DMS English 05/2023 Word No
F-01951A Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis Instructions DMS English 05/2023 PDF No
F-03224 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Uveitis DMS English 10/2023 Word No
F-03224 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Uveitis DMS English 10/2023 PDF No
F-03224A Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Uveitis, Instructions DMS English 10/2023 PDF No
F-02666 Prior Authorization Drug Attachment for Headache Agents, Acute Treatment DMS English 07/2022 PDF No

Glossary

 
Last revised January 24, 2023