• 300 Series
• 400 Series
• 500 Series
• 700 Series
• 1000 Series
• 1200 Series
• 2400 Series

• 3000 Series
• 3100 Series
• 3200 Series
• 3300 Series
• 6000 Series
• 9000 Series
• Misc

300 Series

DMAP 340
Pharmacy Registration for Senior Prescription Drug Assistance Program

DMAP 390
Request to Change Pharmacy

400 Series

DMAP 405T
Medical Transportation Order

DMAP 406
Medical Transportation Eligibility Screening and Medical Transportation Order

DMAP 409
Medical Transportation Screening/Input Document

DMAP 410
Medical Transportation Screening Documentation

DMAP 473
Request for PCCM Enrollment Override

500 Series

DMAP 505
Medicare/Medicaid Billing Invoice (continuous)

DMAP 590
Private Duty Nursing Psychosocial Grid

DMAP 591
Private Duty Nursing Acuity Grid

700 Series

DMAP 720
AI/AN Client Disenrollment

DMAP 729
Administrative Medical Examination and Report Authorization

DMAP 729A
Psychiatric/Psychological Evaluation

DMAP 729C
Eye Exam Report

DMAP 729D
Medical Record Checklist

DMAP 729E
Physical Residual Function Capacity Report

DMAP 729F
Mental Residual Function Report

DMAP 729G
Impairment Severity Rating Report

DMAP 741
Hysterectomy Consent; also in Spanish

DMAP 742A

Consent to Sterilization; also in Spanish

DMAP 742B  

Ages 15-20 Consent to Sterilization; also in Spanish

1000 Series

DMAP 1036
Individual Adjustment Request

DMAP 1038
Register your NPI with OMAP

DMAP 1074
Prior Authorization for Out-of-State Services

1200 Series

DMAP 1274
Home Health Payment Authorization Request

2400 Series

DMAP 2405
Service Denial Notification

DMAP 2410
Newborn Notification

DMAP 2420  

DMAP Forms Request

DMAP 2461
Evaluation of Respiratory Assist Device

DMAP 2486
Incontinence Assessment

DMAP 2470
Maternity Case Management - Initial Assessment

DMAP 2471
Maternity Case Management - Training and Education Tracking

DMAP 2472
Maternity Case Management - Home and Environmental Assessment

DMAP 2473
Maternity Case Management - Five A's Intervention Record (FAIR) for Smoking Cessation

3000 Series

DMAP 3027
FQHC/RHC Cost Statement; also in MS Excel

DMAP 3030
Notice of Hearing Rights

DMAP 3035
Provider Information Update

DMAP 3047
Augmentative Communication Device Selection Summary Report

DMAP 3062
Pharmacy Prescription Volume Survey

DMAP 3063
Facility Dispensing Statement

DMAP 3070
OMAP Authorization Request Cover Sheet

DMAP 3071H
Payment Authorization Request, Audiology/ Hearing Aid Services

DMAP 3071P
Payment Authorization Request and Status Report for Physical and Occupational Therapy

DMAP 3071S
Payment Authorization Request and Status Report for Speech-Language Pathology Services

OMAP 3073
Premium Referral for Private Health Insurance

DMAP 3077
Direct Deposit Authorization form

OMAP 3079  

Notice of TPO Exemption to HIPAA Privacy Requirements

DMAP 3082 
Overview of Services for Children in Foster Care

DMAP 3083

Subsidized Adoptions - Reimbursement Request

OMAP 3084
Request for Transplant Evaluation

DMAP 3086

Subsidized Adoptions - Prior Authorization Request

DMAP 3089
Authorization for Home Enteral/ Parenteral/ Nutrition and IV Services

3200 Series

DMAP 3274

Outreach Quarterly Report to OMAP

3300 Series

DMAP 3301
Dental Hospital Referral

6000 Series

DMAP 6625
Outreach Facility Forms Order Sheet

DMAP 6600 
Outreach Facility Application

DMAP 6670

Outreach Facilities

9000 Series

DMAP 9033
Lead Risk Assessment Questionnaire

Miscellaneous

Form 42
Hospital Cost Settlement form - Excel template

Form 42 instructions
Cost settlement form instructions - Word document

PA Request
Prior Authorization Request (First Health)

MAC Local Match Leveraging Form:

(Word or PDF )

For providers who invoice DMAP for Medicaid Administrative Claiming (MAC) activities.

MMIS Local Match Leveraging Form

(Word or PDF )

For School-Based Health Services, Behavioral Rehabilitative Services, and Targeted Case Management