The DC Department of Health (DC Health) strongly recommends the Measles, Mumps, and Rubella (MMR) vaccine, a safe and effective way to prevent measles, a highly contagious disease. Learn more.

Enrollee Forms

Transportation

HSCSN Family Therapy Travel Fact Sheet [PDF - 370 KB]
HSCSN Unaccompanied Enrollee Consent Form - English [PDF - 956 KB]
HSCSN Unaccompanied Enrollee Consent Form - Spanish [PDF - 1.12 MB]

Pharmacy Benefits

HSCSN CVS Mail Order Fax Form [PDF - 650 KB]
HSCSN Formulary Prior Authorization and Exception Form [PDF - 455 KB]

Out-of-Pocket Reimbursement of Medical Costs

HSCSN Reimbursement Request Form - English [PDF - 2 MB]
HSCSN Reimbursement Request Form - Spanish [PDF - 2 MB]

HSCSN Benefits

HSCSN Benefits Covered [XLS - 36 KB]

Behavioral Health Services Request Forms

HSCSN AprilMay Referral Form [PDF - 712 KB]

Physical Health Services Request Forms

HSCSN Rehabilitative Services Request Form [PDF - 236 KB]

Referrals

HSCSN Out of Network Services Referral Form [PDF - 189 KB]