General
- HSCSN Out of Network Services Referral Form [PDF-795 KB]
- Demographic Provider Change Form [PDF - 580 KB]
- District of Columbia Universal Referral Form [PDF - 750 KB]
- HSCSN Family Therapy Travel Fact Sheet [PDF - 370KB]
- HSCSN Summer Program Request Form [PDF - 92KB]
- Therapeutic School Break Services (TSBS) Request Form [PDF - 128 KB]
Pharmacy Benefit
- Formulary Prior Authorization and Exception Form [PDF-455 KB]
- CVS Mail Order Fax Form [PDF-650 KB]
Order Forms for Behavioral Health Services Requiring Prior Authorization
- HSCSN Provider Request for ABA Form [PDF - 199 kb]
- IN-HOME BEHAVIORAL INTERVENTION REFERRAL FORM [PDF - 676 KB]
- IN-HOME BEHAVIORAL INTERVENTION ISP TOOL [PDF - 265 KB]
- IN-HOME BEHAVIORAL INTERVENTION SERVICE ASSESSMENT TOOL [PDF - 1 MB]
- Neuropsychological Testing Request Form [PDF - 61 KB]
- Psychological Testing Request Form [PDF - 331.52 KB]
- ABA Evaluation Request Form [PDF - 112 KB]
- ABA Telehealth Request Form [PDF - 76 KB]
- HIPAA Form [WORD - 168 KB]
- PRTF Medical Necessity Review Referral Form Template [WORD - 85 KB]
Order forms for Medical Services Requiring Prior Authorization
- Home Care Request Form [PDF - 734 KB]
- DME Request Form [PDF - 72 KB]
- Home Assessment Modifications Request Form [PDF - 141.21 KB]
- Nutritional Supplemental Order Request Form [PDF - 170 KB]
Perinatal Collaborative
- Global Authorization and PsychoSocial Form [PDF - 878 KB]
- Instruction Sheet for Global Authorization and Supplemental Forms [PDF - 12 KB]
- Perinatal Care Coordination Communication Form [PDF - 562 KB]
School Health Services
- HPV Opt-Out Form [PDF - 620 KB]
- District of Columbia Universal Health Certificate [PDF - 711 KB]
- Asthma Action Plan
- Action Plan for Anaphylaxis [PDF - 1 MB]
- Authorization for Medical Administration Form [PDF - 545 KB]
- Authorization for Medical Treatment Form [PDF - 495 KB]