General Forms Eligibility Forms Provider Forms HIPAA Forms

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

Eligibility Forms

Provider Forms

• Prescription Drug Claim Form (DHS Form 204)
• DHS Form 204 Form Instructions
• Prior Authorization Request For Air Transportation, Lodging, Meals And Ground Transportation (DHS Form 208)
  • DHS Form 208 Form Instructions
• Authorization to Disclose Confidential Information BY The Med-QUEST Division Fillable Form (DHS 1123)

  • DHS 1123 Form Instructions
• Authorization To Disclose Information To The Med-QUEST Division Fillable Form (DHS 1124)

  • DHS 1124 Form Instructions
• Medicaid Provider Application/Change Request Form (DHS 1139)
• DHS 1139 Form Instructions - Existing Providers
• DHS 1139 Form Instructions - New Providers
• Psychiatry/Psychology Credentialling Atachment Form (DHS 1139A)
• DHS 1139A Form Instructions
• Non-Emergency Ground Transportation - Taxi Cabs Attachment Form (DHS 1139B)
• DHS 1139B Form Instructions
• Home Health Services Attachment Form (DHS 1139C)
• DHS 1139C Form Instructions
• Acute Hospital Attachment Form (DHS 1139D)
• DHS 1139D Form Instructions
• Nursing Facility Attachment Form (DHS 1139E)
• DHS 1139E Form Instructions
• Intermediate Care Facility For The Mentally Retarded (ICF-MR) Attachment Form (DHS 1139F)
• DHS 1139F Form Instructions
• Early and Periodic Screening, Diagnosis And Treatment Medically Fragile Case Management Provider Attchment Form (DHS 1139G)
• DHS 1139G Form Instructions
• Early And Periodic Screening, Diagnosis And Treatment (EPSDT) Skilled Nursing And Personal Care Provider Attachment (DHS 1139H)
• DHS 1139H Form Instructions
• Request For Medical Authorization Form (DHS 1144)
  • DHS 1144 Form Instructions
• Request For Medical Authorization Of Incontinence Supplies Form (DHS 1144A)
  • DHS 1144A Form Instructions
• Request For Medical Authorization For Home Infusion Or Medication Prior Authorization (PA) Form (DHS 1144B)
  • DHS 1144B Form Instructions
• Request For Prior Authorization Out-of-State Medical Treatment Form (DHS 1144C)
  • DHS 1144C Instructions
• DHS Form 1144E
  • DHS Form 1144E Instructions
• Level Of Care (LOC) Evaluation (DHS 1147)
  • Instruction DHS Form 1147 Level of Care (LOC) Evaluation
• Level Of Care (LOC) Evaluation Re-Evaluation DHS 1147a)
  • Instruction DHS Form 1147a Level of Care (LOC) Re-Evaluation
• Children/Young Under Age 21 Level of Care (LOC) (DHS 1147e)
  • Instructions DHS 1147e Children/Youth Under Age 21 Level of Care (LOC)

HIPAA Forms

Below is a list of currently available HIPAA forms. You will need Adobe Acrobat Reader to view these files. Click here for a free download of Adobe Acrobat Reader.