The following forms are available for download. You will need Adobe Acrobat Reader to view these files.

Application Forms

• Medical Assistance Application DHS 1100
• Medical Assistance Renewal Form DHS 1100B
• Children and Pregnant Women Application Form (DHS 1108)

Other Forms

• Prior Authorization Request For Air Transportation, Lodging, Meals and Ground
  Transportation (DHS form 208)
• Request For Prior Authorization Out-of-State Medical Treatment (DHS 1144C)
• Request For Medical Authorization (DHS 1144)
• Statement Of Intent For Applicant/Recipients in Long Term Care Facilities (DHS 1167)
• Notice of Approval of Interisland Air Transportation
• Supplement to Assignment of Payment (DHS 1125)
• Authorization to Disclose Information by Med-QUEST (DHS 1123)
  • Authorization to Disclose Information by Med-QUEST Instructions 1123
• Authorization to Disclose Information to Med-QUEST (DHS 1124)
  • Authorization to Disclose Information to Med-QUEST Instructions 1124