Bureau of Special Health Care Needs Forms Available from DHSS Warehouse

Updated on 6/2/2008

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4 forms in this list.

Catalog Number Name Quantity Per Unit Program Restrictions

CC-12 INTEROFFICE TRANSMITTAL EACH Bureau of Special Health Care Needs

CC-64 HCY PROVIDER LOG EACH Bureau of Special Health Care Needs

CC-9 PRIOR AUTHORIZATION REQUEST EACH Bureau of Special Health Care Needs

CC-9D PRIOR AUTHORIZATION REQUEST - DENTAL SERVICES EACH Bureau of Special Health Care Needs

Catalog Number	Name	Quantity Per Unit	Program	Restrictions
CC-12	INTEROFFICE TRANSMITTAL	EACH	Bureau of Special Health Care Needs
CC-64	HCY PROVIDER LOG	EACH	Bureau of Special Health Care Needs
CC-9	PRIOR AUTHORIZATION REQUEST	EACH	Bureau of Special Health Care Needs
CC-9D	PRIOR AUTHORIZATION REQUEST - DENTAL SERVICES	EACH	Bureau of Special Health Care Needs