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The District of Columbia Department of Health Care Finance (DHCF) has recently finalized new regulations affecting Medicaid reimbursement for certain out-of-pocket expenses. Learn more.
Provider Forms
General
- HSCSN Provider Practice Information Update Form [PDF - 193 KB]
- HSCSN District of Columbia Universal Referral Form [PDF - 750 KB]
- HSCSN Family Therapy Travel Fact Sheet [PDF - 370 KB]
- HSCSN Summer Program Authorization Request Form [PDF - 72 KB]
- HSCSN Therapeutic School Break Services (TSBS) Request Form [PDF - 128 KB]
Pharmacy Benefit
- HSCSN CVS Mail Order Fax Form [PDF - 650 KB]
- HSCSN Formulary Prior Authorization and Exception Form [PDF - 455 KB]
Behavioral Health Services Request Forms
- HSCSN AprilMay Referral Form [PDF - 712 KB]
- HSCSN HIPAA Form [DOC - 168 KB]
- HSCSN Neuropsychological Testing Request Form [PDF - 61 KB]
- HSCSN Provider Request for ABA Evaluation [PDF - 247 KB]
- HSCSN PRTF Medical Necessity Review Referral Form Template [WORD - 85 KB]
- HSCSN Psychological Testing Request Form [PDF - 332 KB]
Physical Health Services Request Forms
- HSCSN DME Request Form [PDF - 72 KB]
- HSCSN Home Care Services Request Form - [PDF - 661 KB]
- HSCSN Nutritional Supplement Request Form [PDF - 170 KB]
- HSCSN Rehabilitative Services Request Form - [PDF - 236 KB]
Perinatal Collaborative
- HSCSN Global Authorization and PsychoSocial Form [PDF - 878 KB]
- HSCSN Instruction Sheet for Global Authorization and Supplemental Forms [PDF - 12 KB]
- HSCSN Perinatal Care Coordination Communication Form [PDF - 562 KB]
School Health Services
- HSCSN Action Plan for Anaphylaxis [PDF - 1 MB]
- HSCSN Asthma Action Plan [PDF - 353 KB]
- HSCSN Authorization for Medical Administration Form [PDF - 545 KB]
- HSCSN Authorization for Medical Treatment Form [PDF - 495 KB]
- HSCSN District of Columbia Universal Health Certificate [PDF - 711 KB]
- HSCSN HPV Opt-Out Form [PDF - 620 KB]
Referrals
- HSCSN Out of Network Services Referral Form [PDF - 189 KB]