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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-11033A Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA) Completion Instructions DMS English 10/2008 PDF No
F-11066 Prior Authorization / Oxygen Attachment (PA/OA) DMS English 07/2012 PDF No
F-11066 Prior Authorization / Oxygen Attachment (PA/OA) DMS English 07/2012 Word No
F-11066A Prior Authorization / Oxygen Attachment (PA/OA): Completion Instructions DMS English 08/2015 PDF No
F-11016A Prior Authorization / Physician Attachment (PA/PA) Completion Instructions DMS English 07/2012 PDF No
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS English 07/2012 PDF No
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS English 07/2012 Word No
F-11019A Prior Authorization / Physician Otological Report (PA/POR) Completion Instructions DMS English 07/2012 PDF No
F-11305 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease DMS English 01/2016 PDF No
F-11305A Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease: Completion Instructions DMS English 01/2016 PDF No
F-11307 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis DMS English 12/2012 PDF No
F-11307A Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis: Completion Instructions DMS English 07/2015 PDF No
F-11308 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis DMS English 12/2012 PDF No
F-11308A Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis: Completion Instructions DMS English 07/2015 PDF No
F-00694A Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ulcerative Colitis Completion Instructions DMS English 07/2015 PDF No
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents DMS English 07/2013 PDF No
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents DMS English 07/2013 Word No
F-00281A Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents Completion Instructions DMS English 07/2015 PDF No
F-00622 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable DMS English 06/2012 PDF No
F-00280 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Other DMS English 07/2013 PDF No
F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents DMS English 09/2019 PDF No
F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents DMS English 09/2019 Word No
F-11097A Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents: Completion Instructions DMS English 07/2015 PDF No
F-00080 Prior Authorization / Preferred Drug List (PA/PDL) for Symlin DMS English 10/2011 PDF No
F-00080A Prior Authorization / Preferred Drug List (PA/PDL) for Symlin Completion Instructions DMS English 07/2015 PDF No
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) DMS English 07/2012 Word No
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) DMS English 07/2012 PDF No
F-11031A Prior Authorization / Psychotherapy Attachment (PA/PSYA) Completion Instructions DMS English 10/2008 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-11032A Prior Authorization / Substance Abuse Attachment (PA/SAA) Completion Instructions DMS English 10/2008 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 07/2024 PDF No
F-11008 Prior Authorization / Therapy Attachment (PA/TA) DMS English 07/2024 Word No
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS English 10/2020 PDF No
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS English 10/2020 Word 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 Word No
F-11042 Prior Authorization Amendment Request DMS English 07/2012 PDF 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

Glossary

 
Last revised January 24, 2023