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To access eQHealth Solutions web portal, please complete the Provider Contact Form and fax to 601-360-4967.

 Precertification Request Forms


Autism Spectrum Disorder Precertification Form

Expanded Physician Visits Request Form

Therapeutic and Evaluative Mental Health Services Request Form

Hearing Services Request Form

Vision Services Request Form

Dental Services Request Form

Orthodontic Request Form 

Orthodontic Initial Assessment Form w/ Instructions - Revised

Genetic Testing Request Form

Genetic Testing CMN Form

EQHS PT.OT.ST - Certification Request Form

EQHS PT.OT.ST - Certificate of Medical Necessity Form

EQHS PT.OT.ST - Evaluation Form

EQHS PT.OT.ST - Plan of Care Form

Phase II Cardiac Rehabilitation Request Form

DME Plan of Care Form

Updated Oxygen CMN Form - effective 12/1/2018


Updated DME CMN Forms - A thru B

Updated DME CMN Forms - C thru F

Updated DME CMN Forms - G thru N

Updated DME CMN Forms - O thru R

Updated DME CMN Forms - S thru V

Updated DME CMN Forms - W thru Z

Power Wheelchair Environmental Evaluation Form

Diabetes Self-Management Training Request Form

Continuous Glucose Monitoring CMN Form

Continuous Glucose Monitoring Plan of Care Form

PDN/PPEC Forms

Hospice Election Package

Hospice Discharge/Hospice Revocation Form

Hospice Transfer Form

Swingbed Admission Request Form

Swingbed Continued Stay Request Form

Inpatient Med/Surg Admission Request Form

Inpatient Med/Surg Continued Stay Request Form

Retrospective Review Form

Day Treatment Election Statement Form 

Additional Information Form

Freedom of Choice Form

Generic Authorization Request Form
(do not use if an authorization request form is available for the service needed)

Reconsideration Request Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

    
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