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  ***
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 ***

Advanced Imaging Prior Auth Guide

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 and Documents: 
Provider Recovery Reversal Permission Form

Claims Workflow Infographic 

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

*** SCDHHS STATE MANDATED REQUIRED FORMS FOR SUBMISSION