7 days free

AI form filling · 75 fields · 3 pages · done in seconds

Yes! You can use AI to fill out Form CH-006: PA-BH-Res-PCS, Oregon Behavioral Health Support Program Plan of Care Authorization (Plan of Care Request for Behavioral Health Residential or Personal Care Services)

Don't type 75 fields by hand. Tell our AI about yourself, or upload your insurance card, and it fills every field in seconds. You check it, then download, print or sign.

7 days free, then $19.99/month · Cancel anytime

AI fills it, no typingEncrypted, never used to train AICancel in two clicks

Form CH-006: PA-BH-Res-PCS, Oregon Behavioral Health Support Program Plan of Care Authorization (Plan of Care Request for Behavioral Health Residential or Personal Care Services), page 1

Moderate · 46/100Form Complexity Index

The AI does the filling. You just check it.

No typing into boxes, nothing to install.

Tell the AI about youAnswer a few questions in plain words, or upload your insurance card. That is all the typing there is.

AI fills every field in secondsIt puts each answer in the right box on every page, checkboxes included.

Check it and downloadReview every field, change anything, then download, print or sign the PDF.

What this form asks for

The AI fills all of it, from your answers or your documents.

Form CH-006 (PA-BH-Res-PCS) is an Oregon Behavioral Health Support Program plan-of-care authorization request used to obtain approval for 1915(i) behavioral health residential or personal care services. Providers and Community Mental Health Programs (CMHPs) use it to request an initial authorization, a 90-day SRTF reauthorization, a change-in-condition assessment, or an annual redetermination. The form captures member details, legal/guardian status, provider information, level of care, procedure codes/modifiers, and requested service dates/units. Submitting the required supporting clinical documentation is essential for Comagine Health to review and issue or continue service authorization.

Fillable fields75

Pages3

Sections16

Questions that depend on earlier answers6

Form Complexity IndexModerate, 46/100

The AI checks your answers before you download

19 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Member name fields present and non-placeholder

Validates that the Individual/Member Last Name and First Name are both provided and contain alphabetic characters (allowing common punctuation like hyphens and apostrophes). This prevents submissions that cannot be matched to eligibility/clinical records or that contain placeholders (e.g., 'N/A', 'Unknown'). If validation fails, the form should be rejected and routed back for correction because downstream authorization and record matching will be unreliable.

Date of Birth format and plausibility

Checks that Date of Birth is present, follows a valid date format (MM/DD/YYYY), and represents a plausible date (not in the future and not unreasonably old, e.g., >120 years). This is important for identity verification and for age-dependent level-of-care options (e.g., TAY programs). If it fails, block submission and request correction to avoid misidentification and incorrect service placement.

Primary ICD-10 diagnosis code format validation

Ensures the Primary ICD-10 Diagnosis Code is provided and matches ICD-10 formatting rules (e.g., one letter followed by 2 digits, optional decimal and additional characters such as F32.1). Accurate diagnosis coding is required for medical necessity review and correct authorization categorization. If invalid or missing, flag as incomplete and prevent submission until corrected.

Medicaid ID (prime number) required and format/length check

Validates that the Medicaid ID is present and conforms to expected character set and length rules used by the program (e.g., numeric-only if required, or alphanumeric if allowed, with no spaces). This is critical for eligibility verification and linking the request to the correct member record. If validation fails, the request should not proceed because eligibility and prior authorizations cannot be reliably retrieved.

Legal status selection is exactly one and consistent

Checks that exactly one Legal Status option is selected (Voluntary, Voluntary by Guardian, Civil Commitment, PSRB, 370 Aid and Assist). This matters because legal status can drive required documentation (e.g., PSRB conditional release/community evaluation) and care coordination requirements. If multiple or none are selected, the submission should be rejected as ambiguous and returned for clarification.

Guardian information required when legal status implies guardian involvement

If 'Voluntary by Guardian' is selected or guardian involvement is otherwise indicated, validates that Legal Guardian Name, Relationship, Address, Phone, and Email are completed. This ensures legal authority and contactability for consent and participation requirements. If missing, the form should be flagged as incomplete and held until guardian details are provided.

And 13 more checks

Guardian contact format validation (phone and email)
Request type selection is exactly one and drives timing rules
Admission date required/conditional and valid date
County of Responsibility and CCO required fields
Referring provider identifiers and contact information completeness
Rendering provider identifiers and contact information completeness
Level of Care selection is exactly one and compatible with request type
Procedure code required and consistent with Level of Care (including N/A rule)
Modifiers selection validation (allowed set and duplicates)
Units requested is numeric, positive, and reasonable for date span
Dates of Service range validation (format, order, and alignment)
Member/guardian awareness question required and consistent with guardian status
Signature blocks completeness and date validity

Let AI fill out your CH-006 (PA-BH-Res-PCS)

No typing. Every field filled in seconds, checked, ready to sign.

7 days free, then $19.99/month · Cancel anytime

How to Fill Out CH-006 (PA-BH-Res-PCS) Online for Free in 2026

What the AI walks you through.

Select the request type (Initial Request, Annual Redetermination, 90-day SRTF Reauthorization, or Change in Condition) and gather the required supporting documents (e.g., QMHP assessment, care/treatment plan, progress notes, releases, guardianship paperwork if applicable).
Enter Individual/Member Information: name, date of birth, primary ICD-10 diagnosis code, Medicaid ID, and legal status (Voluntary, Civil Commitment, PSRB, etc.).
Complete Guardian Information if applicable: guardian name, relationship, address, phone, and email.
Fill in Request Information: date of admission (if applicable), county of responsibility, CCO, and the Referring Provider’s name, MCD number, phone, email, and fax.
Complete Rendering Provider details: provider name, MCD number, phone, email, and fax.
Select the Level of Care and Procedure Code, choose all applicable modifiers, and enter the number of units requested and dates of service (from/to).
Confirm the individual/guardian is aware of the referral, obtain required signatures (CMHP representative and provider/staff submitting), then submit the completed form and attachments to Comagine Health via fax, secure email, or mail.

Common Mistakes in Completing CH-006 (PA-BH-Res-PCS)

The ones the AI is built to catch.

Missing required supporting documentation or submitting outdated documents

People often submit the CH-006 without the required attachments (especially the QMHP-signed assessment and the Residential Care Plan/Treatment Plan) or they attach versions older than the “within one year of authorization start date” requirement. This happens because the checklist is long and the date rules vary by document type (e.g., SRTF notes most recent 90 days vs. AFH/RTH/RTF notes 6–12 months or most recent 60 days if daily). Missing/expired documentation commonly leads to delays, requests for more information, or denial. Avoid this by using the form’s checklist as a packet cover sheet and verifying each document’s signature and date window before sending.

Selecting the wrong request type (Initial vs Annual vs 90-day SRTF vs Change in Condition)

Applicants frequently check the wrong box under “This request is for,” especially confusing Annual Redetermination with 90-day SRTF Reauthorization or using Change in Condition when the change has not met the 30+ day threshold. The consequences include the request being processed under the wrong timeline, missing the correct documentation set, or being rejected as premature. This mistake happens because the acceptance windows (60 days prior, 30 days prior, after 30+ days) are easy to overlook. Avoid it by confirming the current authorization end date and matching it to the correct submission window before selecting the request type.

Incorrect or incomplete member identifiers (Medicaid ID, DOB, ICD-10 code)

A common error is entering an incomplete Medicaid ID (or using a non-prime/incorrect number), transposing digits in the date of birth, or listing a non-specific/incorrect ICD-10 code. These mistakes happen due to copying from older records or mixing identifiers from different systems. The result is delayed matching to the correct member record, requests for clarification, or processing under the wrong diagnosis. Avoid this by copying directly from the member’s current eligibility/registration record and double-checking the ICD-10 format and accuracy.

Leaving legal status blank or choosing a status that conflicts with attachments

People often skip the Legal Status selection or choose a status (e.g., PSRB, Civil Commitment, Voluntary by Guardian) that doesn’t align with the documentation provided. This can trigger follow-up requests, especially when PSRB is selected but the Conditional Release/Community Evaluation is not included, or when guardianship is indicated but paperwork is missing. The confusion usually comes from not knowing which legal category applies at the time of submission. Avoid this by confirming the current legal status in the chart/court documents and attaching the corresponding required paperwork.

Providing guardian information inconsistently or omitting guardianship paperwork

A frequent issue is filling in guardian fields without attaching legal guardianship documentation, or selecting “Voluntary by Guardian” while leaving guardian name/relationship/contact blank. This happens when staff assume guardianship is “on file” elsewhere or misunderstand when it is required. Consequences include delays, inability to confirm consent, and potential compliance issues for releases and participation consent. Avoid this by completing all guardian fields whenever a guardian is involved and always including the guardianship paperwork and guardian-signed consent when applicable.

Wrong level of care selection (AFH/RTH/RTF/SRTF/DD/APD/TAY/Independent Living)

Submitters sometimes select a level of care that doesn’t match the placement (e.g., checking RTF instead of SRTF, or selecting APD RCF/ALF when the setting is a DD Group Home). This often occurs because acronyms are similar and some settings overlap in everyday language. The consequence can be incorrect authorization parameters, mismatched procedure codes, or a request for resubmission. Avoid this by verifying the licensed setting type and program category (APD vs DD vs TAY) before checking the box.

Procedure code/modifier errors (wrong code, missing modifiers, or selecting N/A incorrectly)

Common mistakes include choosing the wrong procedure code, forgetting required modifiers, selecting modifiers that don’t apply, or marking “N/A (Independent Living)” while also requesting a residential level of care. These errors happen because coding rules are easy to mix up across settings and staff may reuse old templates. Consequences include claim/authorization mismatches, rework, and processing delays. Avoid this by confirming the correct code/modifier combination for the selected level of care and ensuring the selection is internally consistent across the form.

Units requested and dates of service don’t align (math and timeframe issues)

People often enter “Number of Units Requested (over full duration)” that doesn’t match the From/To dates, or they leave dates blank, use the wrong format, or request dates outside the allowable authorization period. This happens when the unit calculation is done separately or when the admission date is confused with the authorization start date. The result is follow-up questions, partial approvals, or denial for incorrect service periods. Avoid this by calculating units based on the exact From/To range and using MM/DD/YYYY consistently for admission and service dates.

Missing admission date when required or using an incorrect date format

For requests tied to residential admission, submitters sometimes omit the “Date of Admission to Residential Program” or enter it in a non-MM/DD/YYYY format. This occurs because the field is labeled “if applicable,” leading people to assume it’s optional even when it’s needed to establish timing for an initial request or placement. Missing/incorrect admission dates can delay review and create confusion about eligibility and service start. Avoid this by including the admission date whenever the member is in (or entering) a residential program and formatting it exactly as MM/DD/YYYY.

Incomplete provider information (MCD number, contact details, or mixing referring vs rendering provider)

A common problem is leaving the MCD number blank, providing a facility name without the correct provider identifier, or entering the rendering provider details in the referring provider section (and vice versa). This happens when multiple organizations are involved and staff are unsure who should be listed where. Consequences include delays in contacting the right party, misrouted determinations, and authorization issued to the wrong provider. Avoid this by confirming which entity is the referrer vs renderer and ensuring each section includes the correct MCD number, phone, email, and fax.

Missing required signatures, names/titles, or dates

Submissions are often missing one of the two required signature lines (CMHP Representative and Provider/Staff Submitting Form), or they include a signature without printed name/title and date. This happens when forms are routed between teams and one party assumes the other will sign later. The consequence is an incomplete request that cannot be processed until corrected. Avoid this by verifying both signature blocks are fully completed (signature, name and title, and date) before faxing/emailing/mailing the packet.

Frequently Asked Questions About CH-006 (PA-BH-Res-PCS)

Is it really free for 7 days?

Yes. You pay $0 today. Cancel before Nov 1 and you are never charged. Keep it, and it is $19.99 a month for 5 fills of your CH-006 (PA-BH-Res-PCS).

Can I fill other forms too?

This plan is for your CH-006 (PA-BH-Res-PCS): your own AI agent fills it as often as 5 times a month. To fill other forms and upload your own, choose a Professional plan from your account.

How do I cancel?

From your account, in two clicks, any time. No email, no call.

How does the AI fill out CH-006 (PA-BH-Res-PCS)?

You answer a few questions in plain words, or upload your insurance card. The AI reads what you give it and puts each answer into the right field of CH-006 (PA-BH-Res-PCS), on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.

What happens to my information?

It is encrypted in transit and at rest, and it is never used to train AI.

How complex is CH-006 (PA-BH-Res-PCS) to fill out?

CH-006 (PA-BH-Res-PCS) has a Form Complexity Index of 46 out of 100, in the moderate tier: 75 fillable fields across 3 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.

What is Form CH-006 (PA-BH-Res-PCS) used for?

Form CH-006 is used to request authorization for Oregon Behavioral Health Support Program 1915(i) services for Behavioral Health Residential or Personal Care Services. It supports initial determinations, 90-day SRTF reauthorizations, change-in-condition assessments, and annual redeterminations.

Who should complete and submit this form?

The form is typically completed and submitted by the provider or staff requesting services, along with the Community Mental Health Program (CMHP) representative. Both the CMHP representative and the provider/staff submitting the form must sign.

Where do I send the completed CH-006 form?

You can submit the completed form to Comagine Health by fax (877-575-8309), secure email ([email protected]), or mail to Comagine Health – OBHSP, 650 NE Holladay St., Suite 1700, Portland, OR 97232.

What supporting documents are required with the request?

Required items (marked with an asterisk on the form) generally include a QMHP-signed Mental/Behavioral Health Assessment within one year, a Residential Care Plan/Treatment Plan within one year, and applicable progress notes. Other required documents may include PSRB Conditional Release/Community Evaluation and legal guardianship paperwork when applicable.

How recent do progress notes need to be?

For AFH/RTH/RTF, submit 6–12 months if notes are monthly/weekly, or the most recent 60 days if notes are daily. For SRTF, submit daily clinical, nursing, and psychiatric notes for the most recent 90 days; for change in condition/status, provide 30+ days of notes.

When can I submit an Annual Redetermination request?

Annual redetermination referrals are accepted 60 days prior to the end of the current plan of care. Comagine Health also notifies providers 60 days before the current authorization end date and requests annual redetermination documentation.

When can I submit a 90-day SRTF Reauthorization request?

A 90-day SRTF reauthorization referral is accepted 30 days prior to the end of the current plan of care. Comagine Health will request documentation for these reauthorizations 30 days before the current authorization ends.

What qualifies as a Change in Condition request, and when is it accepted?

A Change in Condition request is used when there has been a change in the individual’s status that affects service needs. The form indicates these referrals are accepted after 30+ days of change in status, and you should include 30+ days of related progress notes.

What member information is required in the Individual/Member Information section?

You must provide the individual’s name, date of birth, primary ICD-10 diagnosis code, Medicaid ID (prime number), and legal status. If the person has a guardian, you must also complete the guardian information section.

How do I choose the correct legal status on the form?

Select the one option that matches the individual’s current legal status: Voluntary, Voluntary by Guardian, Civil Commitment, PSRB, 370, or Aid and Assist. If the person is under guardianship or PSRB involvement, include the required supporting legal documents.

What provider details are required for the Referring Provider and Rendering Provider sections?

Both sections request the provider name, MCD number, phone number, email address, and fax number. The rendering provider is the provider delivering the services, while the referring provider is the one initiating the referral.

How do I select the correct Level of Care and Procedure Code?

Choose one Level of Care option that matches the placement (e.g., AFH, RTH, SRTF, RTF, APD RCF, ALF, DD AFH, DD Group Home, Independent Living, etc.). Then select the appropriate procedure code (T1020, S5140, S5141, or N/A for Independent Living) and any applicable modifiers (HK, HE, TG, HW).

What dates should I enter for Dates of Service and admission date?

Enter the requested service span in the Dates of Service “From” and “To” fields using MM/DD/YYYY. If applicable, also provide the Date of Admission to the Residential Program in MM/DD/YYYY.

Do I need the individual’s or guardian’s consent/awareness to submit the referral?

The form asks whether the individual/guardian is aware the referral is being submitted on their behalf, so you should answer Yes or No accurately. A signed Consent for Release of Information and Participation in the Oregon Behavioral Health Support Program is listed as supporting documentation (signed by the guardian if applicable).

What additional documents might be required for specific situations (PSRB, APD/DD placements, or identified risks)?

If the individual is involved with PSRB, include the Conditional Release/Community Evaluation. For APD/DD placements, include the APD/DD license; if there are identified risks (e.g., suicide, choking, falls, elopement), include a Risk Management Plan, and include incident reports and nursing delegation forms (CH-011) if applicable.

Encrypted in transit and at restNever used to train AIDelete your forms any time

Get your CH-006 (PA-BH-Res-PCS) filled out by AI

$0 today. Cancel before Nov 1 and you pay nothing.

Other forms like this one

CAR forms: Form SSA-44, Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event, Form I-90, Application to Replace Permanent Resident Card, Form 2441, Child and Dependent Care Expenses, Form WH-380-E, Certification of Health Care Provider, Form 4137, Social Security and Medicare Tax on Unreported Tip Income, Form 8959, Additional Medicare Tax, Form 8919, Uncollected Social Security and Medicare Tax, Form CMS-1763, Request for Termination of Medicare Coverage, Form CMS-855O, Medicare Enrollment Application, Form CMS-460, Medicare Participation Agreement, Form CMS-4040, Request for Enrollment in Medicare Part B, Form WH-380-F, Certification of Health Care Provider, Form W-10, Dependent Care Provider’s Identification, Form 1099-K, Payment Card and Third Party Network Transactions, Form CMS-40B, Application for Enrollment in Medicare Part B, Form SS-5-FS, Application for a Social Security Card, Form REG 195, Disabled Person Placard, Form AR-11, Alien's Change of Address Card, Form I-905, Application for Authorization to Issue Certification for Health Care Workers, Form I-131A, Application for Carrier Documentation

health care forms: Form WH-380-E, Certification of Health Care Provider, Form WH-380-F, Certification of Health Care Provider, Form I-905, Application for Authorization to Issue Certification for Health Care Workers, DHS-6696-ENG, Minnesota Health Care Programs Application (MNsure/DHS), Prior Authorization (PA) Request Form – Adult Palliative Care (Alameda Alliance for Health), Medicare Enrolment Application (Australia) – Enrol in Medicare, Re-enrol/Extend Eligibility, Enrol a Newborn, and Register for My Health Record, Alameda Alliance for Health Prior Authorization (PA) Request Form – Adult Palliative Care, Health Assessment – Ontario Health atHome (Fixing Long-Term Care Act, 2021) (Form 4768-69E), Health Assessment - Ontario Health atHome (Fixing Long-Term Care Act, 2021) — Form 4768-69E, Request for Transfer of Records (Adelaide Health Care) – AHC-0013-05-PS (Version 2), Application for Access to Health Care Records (Nepean Blue Mountains Local Health District) – NBMA-431, L.A. Care Behavioral Health Treatment Applied Behavioral Analysis Authorization Request Form, Medicaid Managed Care Applied Behavior Analysis — Authorization Request (Healthy Blue Louisiana, BLAPEC-1989-20), Iowa Advance Directive: Durable Power of Attorney for Health Care and Declaration (Living Will), Direct Rollover Request for Appalachian Regional Healthcare, Inc. Voluntary Plan, Molina Healthcare Prior Authorization Request Form, UnitedHealthcare Prior Authorization Request Form, Optum Rx / UnitedHealthcare Prior Authorization Request Form, Texas Standard Prior Authorization Request Form for Health Care Services, Form T-3, Children with Special Health Care Needs (CSHCN) Services Program Application

behavioral health forms: Form BHVH, Outpatient Behavioral Health – ABA Treatment Request, Geisinger Health Plan Behavioral Health Professional Services Questionnaire, Applied Behavioral Analysis (ABA) Prior Authorization Request Form (Health Net Behavioral Health Autism Center), L.A. Care Behavioral Health Treatment Applied Behavioral Analysis Authorization Request Form, Health Net Applied Behavioral Analysis (ABA) Recommendation and Referral Form (24-989), Evernorth Behavioral Health Applied Behavior Analysis Prior Authorization Form (PCOMM-2025-224), Applied Behavioral Analysis (ABA) Authorization Form, Louisiana Health Connect (BRO-DP-ABA FORM-0822), Form 5385BSP, Behavioral Health Utilization Management Applied Behavioral Analysis (ABA) Initial Request Form, Outpatient Behavioral Health (BH) – ABA Treatment Request: Required Information for Precertification (GR-69017-4), Highmark Health Options Applied Behavioral Analysis (ABA) Prior Authorization Request Form, Biopsychosocial Assessment and ABA Treatment Plan, Colorado OBH Critical Incident Report, Behavioral Health Treatment/Applied Behavioral Analysis/Autism Services Recommendation Form, Form CARE-102, Petition to Begin CARE Act Proceedings By Licensed Behavioral Health Professional Only, Outpatient Behavioral Health (BH) – ABA Treatment Request: Required Information for Precertification

authorization forms: Form I-765, Application for Employment Authorization, Form CMS-588, EFT Authorization Agreement, Form 8821, Tax Information Authorization, Form 8879, IRS e-file Signature Authorization, Form SSA-827, Authorization to Disclose Information, Form I-905, Application for Authorization to Issue Certification for Health Care Workers, Form G-1650, Authorization for ACH Transactions, Arizona Form 285, General Disclosure/Representation Authorization Form, Arizona Form 285-I, Individual Income Tax Disclosure/Representation Authorization Form, The Department of Medical Assistance Services Applied Behavior Analysis Preservice Service Authorization Request Form (Effective Dates of Service 09/01/2025 and after), Continental American Insurance Company (CAIC) / Aflac Group Critical Illness Claim Form (with Attending Physician’s Statement, HIPAA Authorization to Obtain Information, and Electronic Funds Transaction Authorization), HIPAA Authorization Form, Authorization for the Release of Protected Health Information, Form G-1450, Authorization for Credit Card Transactions, Prior Authorization (PA) Request Form – Adult Palliative Care (Alameda Alliance for Health), Alameda Alliance for Health Prior Authorization (PA) Request Form – Adult Palliative Care, Manulife Group Benefits Drug Prior Authorization Form – Mounjaro (Tirzepatide) (GL5197E), Manulife Group Benefits Drug Prior Authorization Form (Ozempic/Semaglutide) – GL5197E, Out-of-Network Pre-Authorization and Exception Request Form, Form SSA-827 (06-2024), Authorization to Disclose Information to the Social Security Administration (SSA), Manulife Group Benefits Drug Prior Authorization Form (Wegovy/Semaglutide) – GL5197E - MLI (08/2025-WEGOV)

service authorization forms: The Department of Medical Assistance Services Applied Behavior Analysis Preservice Service Authorization Request Form (Effective Dates of Service 09/01/2025 and after), Department of Medical Assistance Services Applied Behavior Analysis (97155, Et al.) Initial Service Authorization Request Form, Applied Behavior Analysis Concurrent Service Authorization Request Form (CPT Codes 97153, 97154, 97155, 97156, 97157, 97158, 0373T) – Virginia Department of Medical Assistance Services, Plan–to-Plan Transfer, Plan Exchange, or Service Credit Authorization Form, Empower Plan Service Center Authorization Form (PSC Plan Sponsor Username Request Form), Texas Standard Prior Authorization Request Form for Health Care Services, Merrill RMD Service Enrollment and Authorization Form, Anthem Blue Cross Community-Based Adult Services (CBAS) Authorization Request Form, Request for Authorization for Applied Behavior Analysis (ABA) Services, Applied Behavior Analysis (ABA) Services Request for Authorization Form, Service Authorization Request Form, Community Based Adult Services (CBAS) Treatment Authorization Request

L.A. Care forms: Form SSA-44, Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event, Form 2441, Child and Dependent Care Expenses, Form WH-380-E, Certification of Health Care Provider, Form 4137, Social Security and Medicare Tax on Unreported Tip Income, Form 8959, Additional Medicare Tax, Form 8919, Uncollected Social Security and Medicare Tax, Form CMS-1763, Request for Termination of Medicare Coverage, Form CMS-855O, Medicare Enrollment Application, Form CMS-460, Medicare Participation Agreement, Form CMS-4040, Request for Enrollment in Medicare Part B, Form WH-380-F, Certification of Health Care Provider, Form W-10, Dependent Care Provider’s Identification, Form CMS-40B, Application for Enrollment in Medicare Part B, Form I-905, Application for Authorization to Issue Certification for Health Care Workers, DHS-6696-ENG, Minnesota Health Care Programs Application (MNsure/DHS), California Department of Social Services (CDSS) Community Care Licensing Child Care Forms Packet (LIC 9150, LIC 282, LIC 627, LIC 700, LIC 995A, CDPH 286, LIC 9227), State of Illinois Department of Human Services (IDHS) – Bureau of Child Care and Development Child Care Application (Form IL444-3455), State of Illinois Department of Children and Family Services Medical Report on an Adult in a Child Care Facility (CFS 602), Carer Payment and Carer Allowance – Medical Report (SA431) for a child under 16 years, Pennsylvania Application for Subsidized Child Care (CY 868)

health services forms: Geisinger Health Plan Behavioral Health Professional Services Questionnaire, California Department of Social Services Form RFA 07 (2/18), Resource Family Approval (RFA) Health Questionnaire (Mandatory), Texas Standard Prior Authorization Request Form for Health Care Services, Form T-3, Children with Special Health Care Needs (CSHCN) Services Program Application, Behavioral Health Treatment/Applied Behavioral Analysis/Autism Services Recommendation Form, Blue Shield Promise Community Health Worker (CHW) Services Recommendation Form, Community Health Worker (CHW) Services Request for Extension of Services, San Francisco Health Plan (SFHP) Doula Services Attestation Form, Health & Human Services Agency California Department of Social Services APPLICATION FOR A FAMILY CHILD HOME LICENSE LIC 279

health forms: Form 1095-A, Health Insurance Marketplace Statement, Form 8889, Health Savings Accounts, Form WH-380-E, Certification of Health Care Provider, Form 7206, Self-Employed Health Ins. Ded., Form 8885, Health Coverage Tax Credit, Form WH-380-F, Certification of Health Care Provider, Form 1095-C, Employer-Provided Health Insurance Offer and Coverage, Form 1095-B, Health Coverage, Form I-905, Application for Authorization to Issue Certification for Health Care Workers, Form BHVH, Outpatient Behavioral Health – ABA Treatment Request, Form SHA, Separation Health Assessment, DHS-6696-ENG, Minnesota Health Care Programs Application (MNsure/DHS), Geisinger Health Plan Behavioral Health Professional Services Questionnaire, Priority Health Small Group Renewal Decision Form, Form 7206 (2025), Self-Employed Health Insurance Deduction, HIPAA Authorization Form, Authorization for the Release of Protected Health Information, Prior Authorization (PA) Request Form – Adult Palliative Care (Alameda Alliance for Health), Medicare Enrolment Application (Australia) – Enrol in Medicare, Re-enrol/Extend Eligibility, Enrol a Newborn, and Register for My Health Record, Alameda Alliance for Health Prior Authorization (PA) Request Form – Adult Palliative Care, Health Assessment – Ontario Health atHome (Fixing Long-Term Care Act, 2021) (Form 4768-69E)

health care program forms: Form T-3, Children with Special Health Care Needs (CSHCN) Services Program Application, DHS-6696-ENG, Minnesota Health Care Programs Application (MNsure/DHS), Indiana Health Coverage Programs (IHCP) Managed Care Entity (MCE) Provider Enrollment Form, New York State Department of Health Medicare Savings Program Application

7 days free, then $19.99/month · Cancel anytime