Frequently Used Forms
To access additional forms, including the latest copy of the
Consent for Sterilization Form, please visit the SCDHHS Provider Manual Forms section:
https://www.scdhhs.gov/internet/pdf/manuals/Physicians/Forms.pdf
To access additional forms, including the latest copy of the
Consent for Sterilization Form, please visit the SCDHHS Provider Manual Forms section:
https://www.scdhhs.gov/internet/pdf/manuals /Physicians/Forms.pdf
Healthcare Services Forms:
Health Education Referral Form
Disease Management/Case Management Referral Form
Delivery Notification Form
Neonatal Transfer Form
Pregnancy Notification Report
Abortion Statement
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SBIRT Integrated Screening Tool
Prior Authorization Forms:
Universal Prior Authorization Form BabyNet
BH Prior Authorization-Outpatient Treatment-Higher Level of Care Form
Prior Authorization Request Form
Prior Authorization Medications Form
Universal Synagis Prior Authorization Form ***
Provider Network/Credentialing Forms:
Credentialing Checklist
Credentialing Packet
Practice Demographics Form
Provider Change Form
Primary Care Provider Change Request Form
Contract Request Form
Facility HDO Form
Attachment C Provider Roster
SCDHHS Ownership Form ***
Non Medicaid Enrolled Ownership Disclosure Form
Claims Forms:
Provider Recovery Reversal Permission Form
Provider Faxes:
POD Data Verification Fax
HealthMap General Provider Notice Fax
Pharmacy Timeliness PA Changes Fax
Fax Size Submission
Progeny Provider Notification
Nursing Facility Admissions Update
Advanced Imaging Fax
Fall Updates fax