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• B01 to B33 Form 1139 Provider Application & Instructions with HIPAA Language
• B34 to B35 Form 1149 Request for Emergency Process

• C001 ADA Claim Form 1999 Version 2000
• C003 to C008 Form 1135 Instructions
• C009 Form 1136 Taxi Trip Record
• C010 to C011 Form 1136 Instructions
• C012 Form 1145 Hysterectomy Acknowledgement
• C013 to C014 Form 1145 Instructions
• C015 Form 1146 Sterilization Consent
• C016 to C018 Form 1146 Instructions
• C019 Form 1160 Individual Transportation
• C020 to C023 Form 1160 Instructions
• C024 to C025 CMS 1500 Claim Form
• C026 Form 204 Prescription Claim Form
• C027 Form 204 Instructions
• C028 Form 208 Air Transportation Request
• C029 to C030 Form 208 Instructions
• C031 to C032 UB-04 Claim Form

• F001 to F041 Definition of Codes
• F42 to F85 Drug Coverage Criteria
• F86 to F93 DUR Drug Use Review Program
• F94 to F101 DURS Prospective DUR
• F102 to F104 EPSDT Complete Dental Services Guidelines
• F105 to F111 Home Pharmacy Services Codes
• F112 to F116 Medicaid Guidelines for Home Health
• F117 to F135 Medically Fragile Case Management
• F136 Foreign Language List
• F137 Opioid Treatment Page 1 of 2
• F143 to F145 Outpatient Supplies Memo
• F149 to F150 Ostomy Supplies Memo
• F151 Ostomy Attachment Final Version
• F160 to F164 Rehabilitative Services for Children
• F165 Adult Preventive Health
• F168 to F172 SMI Criteria
• F173 to F176 SMI Evaluation Process
• F177 SMI Medicaid Option Letter
• F179 to F180 SMI Referral Attachment
• F181 SMI Referral Form Revised
• Form 1135 Taxi Authorization Invoice