Healthcare Documents

This file is used by healthcare providers to authorize special formulas and WIC supplemental food for women, infants, and children with qualifying medical conditions. The form ensures that special formulas for non-specific symptoms are not issued. It includes sections for participant information, special formula requests, and healthcare provider details.

This file is for parents/guardians who wish to decline vaccinations for their child. It includes information on the risks and implications of not vaccinating. Signed by both parent/guardian and healthcare provider.

This file is an application form for the Lighthouse Women's Residence Program. It includes sections for referral information, client information, children's details, diagnosis, and treatment history. All information must be completed by a referring party before being considered for admission.

This form from Primary Care Plus outlines the patient's responsibility for payment and provides information on HIPAA notice and patient communication. It explains the patient's obligations regarding insurance, co-pays, and deductibles, and includes an authorization for Medicare and Medicaid benefits. The form also addresses the release of medical information and appointment reminders.

This file is a required document by the Florida Department of Health for the tattooing of a minor child aged 16 through 17. The form must be completed by the minor's parent or legal guardian and notarized. It provides legal consent for a minor to get a tattoo.

This file provides information about Medicare Outpatient Observation Notice, payment details, and instructions for patients. It helps patients understand the costs and coverage associated with observation services. Additionally, it includes sections for signature and additional information.

This file is a comprehensive orientation guide for providers joining the Empire BlueCross BlueShield Managed Long-Term Care (MLTC) network. It covers important topics such as the provider website, authorization process, claims submission, appeals and grievances, compliance program, fraud prevention, HIPAA, and cultural competency. Providers will find all the necessary information to ensure a successful partnership with Empire.

The Lower Extremity Functional Scale (LEFS) is a questionnaire with 20 questions about a person's ability to perform everyday tasks. It helps clinicians measure patients' initial function, ongoing progress, and outcome. It is useful for evaluating functional impairment and monitoring patient progress over time.

The District of Columbia Medicaid 719A form is used to request authorization for medical and surgical services for Fee-for-Service Medicaid beneficiaries. The form includes sections to certify face-to-face encounters, request various services, and document necessary provider information. It is essential for proper documentation and request approval.

This file is a Therapeutic Phlebotomy Order form from LifeSouth Community Blood Centers. It includes instructions for physicians on how to complete the form, as well as patient information and order details. The form must be completed by a physician or advanced practice provider and faxed to LifeSouth.

This file provides information about the dental examination requirements for students entering Pre-K and Kindergarten. It includes guidelines on when the examination should be completed and how to provide proof. It helps ensure children have good oral health for school success.

This form is used to collect information to determine third-party liability for injuries requiring medical care. It allows the United States to recover medical expenses from the party responsible for the injury. Failure to complete this form will result in delays or denial of your TRICARE claim.