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]