F-47470 |
Change of EMS Medical Director |
DPH |
English |
02/2022 |
Word |
No |
F-02562 |
Disability Benefit Specialist Program Client Services Agreement |
DPH |
English |
02/2022 |
HTML |
No |
F-02562LP |
Disability Benefit Specialist Program Client Services Agreement, Large Print |
DPH |
English |
02/2022 |
Word |
No |
F-02562A |
Disability Benefit Specialist Program Client Services Agreement, Instructions |
DPH |
English |
02/2022 |
PDF |
No |
F-02562S |
Disability Benefit Specialist Program Client Services Agreement, Spanish |
DPH |
Spanish |
02/2022 |
Word |
No |
F-02562 |
Disability Benefit Specialist Program Client Services Agreement |
DPH |
English |
02/2022 |
Word |
No |
F-02925 |
Request for HIV Care Grievance Resolution |
DPH |
English |
01/2022 |
Word |
No |
F-02941 |
Community Engagement Assessment Tool (Simplified) |
DPH |
English |
01/2022 |
HTML |
No |
F-02635 |
Release from Isolation Quarantine Calculator |
DPH |
English |
01/2022 |
Excel |
No |
F-00555T |
WIC CARS Expenditure Report Tribal Workbook |
DPH |
English |
01/2022 |
Excel |
No |
F-00555 |
WIC CARS Expenditure Report Workbook |
DPH |
English |
01/2022 |
Excel |
No |
F-26003S |
Notice of Privacy Practices - Treatment Facilities - HCC, Spanish |
DCTS |
Spanish |
01/2022 |
PDF |
No |
F-26003S |
Notice of Privacy Practices - Treatment Facilities - HCC, Spanish |
DCTS |
Spanish |
01/2022 |
Word |
No |
F-26003H |
Notice of Privacy Practices - Treatment Facilities - HCC, Hmong |
DCTS |
Hmong |
01/2022 |
PDF |
No |
F-26003 |
Notice of Privacy Practices - Treatment Facilities - HCC |
DCTS |
English |
01/2022 |
PDF |
No |
F-02815A |
Prior Authorization for Hospital Prolonged Stay Fax Cover Sheet |
DMS |
English |
01/2022 |
PDF |
No |
F-26003 |
Notice of Privacy Practices - Treatment Facilities - HCC |
DCTS |
English |
01/2022 |
Word |
No |
F-02815 |
Prior Authorization for Hospital Prolonged Stay Fax Cover Sheet |
DMS |
English |
01/2022 |
Word |
No |
F-26003H |
Notice of Privacy Practices - Treatment Facilities - HCC, Hmong |
DCTS |
Hmong |
01/2022 |
Word |
No |
F-02106 |
Adult Day Care Center - Applicant Compliance Statement |
DQA |
English |
01/2022 |
Word |
No |
F-02927 |
Nurse Aide Training Prohibition Waiver Request |
DQA |
English |
01/2022 |
HTML |
No |
F-82064S |
Background Information Disclosure (BID), Spanish |
DQA |
Spanish |
01/2022 |
PDF |
No |
F-82064A |
Background Information Disclosure (BID) Instructions |
DQA |
English |
01/2022 |
PDF |
No |
F-82064 |
Background Information Disclosure (BID) |
DQA |
English |
01/2022 |
PDF |
No |
F-82064AS |
Background Information Disclosure (BID) Instructions, Spanish |
DQA |
Spanish |
01/2022 |
PDF |
No |
F-82064H |
Background Information Disclosure (BID), Hmong |
DQA |
Hmong |
01/2022 |
PDF |
No |
F-82064AH |
Background Information Disclosure (BID) Instructions, Hmong |
DQA |
Hmong |
01/2022 |
PDF |
No |
F-11237 |
Specialized Medical Vehicle Providers Affidavit |
DMS |
English |
01/2022 |
PDF |
No |
F-11237 |
Specialized Medical Vehicle Providers Affidavit |
DMS |
English |
01/2022 |
Word |
No |
F-02237 |
Pre-Hire Driving Record Review |
DES |
English |
01/2022 |
Word |
No |
F-02467 |
Children's Long-Term Support: Care Level Classification |
DMS |
English |
01/2022 |
Word |
No |
F-01672A |
Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants, Instructions |
DMS |
English |
01/2022 |
PDF |
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-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-11077A |
Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Instructions |
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-00232CM |
Notice of Adverse Benefit Determination (Notice of Action), Chinese Mandarin |
DMS |
Chinese Mandarin |
12/2021 |
Word |
No |
F-00232 |
Instructions |
DMS |
English |
12/2021 |
PDF |
No |
F-00232SE |
Notice of Adverse Benefit Determination (Notice of Action), Serbo-Croatian |
DMS |
Serbian (Serbo-Croatian) |
12/2021 |
Word |
No |
F-00232AR |
Notice of Adverse Benefit Determination (Notice of Action), Arabic |
DMS |
Arabic |
12/2021 |
Word |
No |
F-00232H |
Notice of Adverse Benefit Determination (Notice of Action), Hmong |
DMS |
Hmong |
12/2021 |
Word |
No |
F-00232L |
Notice of Adverse Benefit Determination (Notice of Action), Laotian |
DMS |
Laotian |
12/2021 |
Word |
No |
F-00232 |
Notice of Adverse Benefit Determination (Notice of Action) |
DMS |
English |
12/2021 |
Word |
No |
F-00232SO |
Notice of Adverse Benefit Determination (Notice of Action), Somali |
DMS |
Somali |
12/2021 |
Word |
No |
F-00232S |
Notice of Adverse Benefit Determination (Notice of Action), Spanish |
DMS |
Spanish |
12/2021 |
Word |
No |
F-00367 |
Functional Eligibility Screen for Children's Long-Term Support Programs (PDF, 122 KB) |
DMS |
English |
12/2021 |
PDF |
No |
F-02923 |
WIIN Grant Child Care Provider Questionnaire |
DPH |
English |
12/2021 |
HTML |
No |
F-01700 |
Exception-to-Policy Request |
DPH |
English |
12/2021 |
Word |
No |
F-02106B |
Adult Day Care Center: Certification Application Checklist |
DQA |
English |
12/2021 |
Word |
No |
F-02111 |
Assisted Living - Fit and Qualified Application for Community-Based Residential Facilities, Adult Family Homes and Adult Day Care Centers |
DQA |
English |
12/2021 |
Word |
No |