Universal U-First^® Medicaid Forms

English Forms

• Informed Consent Form - Psychotherapeutic Medication
• HIV/HEP-B Diagnosis Verification Form
• Medicaid Member Questionnaire
• Enhanced Benefits Universal Form - Reform Only
• Over-the-Counter Order Form
• Medical Record Release Form
• Prescription Drug Prior Authorization Form
• Mental & Behavioral Health Prescription Drug Request Form
• Medicaid Suboxone Prior Authorization Form
• FDA MedWatch Brand Only Prescription Drug Request Form

Spanish Forms (Español)

• Medicaid Member Questionnaire
• Enhanced Benefits Universal Form - Reform Only
• Over-the-Counter Order Form
• Medical Record Release Form