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Forms

The following PDF documents are available for download.

  • Care Management Referral Form
  • Disclosure of Medical Information Authorization Form
  • Health Risk Questionnaire (HRQ) Adult
  • Health Risk Questionnaire (HRQ) Child
  • Outpatient Therapies fax cover sheet
  • PHQ-9 Depression Screening
  • Prior Authorization for Podiatry Services fax cover sheet
  • Provider Instructions for requesting In-State Occupational Therapy Services for MaineCare Members age 21 and over
  • Provider Instructions for requesting In-State Physical Therapy Services for MaineCare Members age 21 and over

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