Articles
AL_Medicaid Pharmacy Prior Authorization Form
This is a sample of the Alabama Medicaid Pharmacy Prior Authorization form 369.
AL_Preparticipation PE Form
This is a sample of the the Alabama High School Athletic Association Participation Physical Evaluation Form 5.
AR_Well Child EPSDT Form
This is a sample of the Arkansas Better Chance Program - Well Child Screening (EPSDT) form.
AZ_EPSDT (15 months) Form
This is a sample of the Arizona AHCCCS EPSDT Tracking form for a 15-month old patient.
AZ_Interscholastic Pre-participation Exam Form
This is a sample of the Arizona Interscholastic Pre-participation Exam form.
AZ_Preparticipation Physical Evaluation - History and Physical Examination Form
This is a sample of the the Arizona Preparticipation Physical Evaluation - History and Physical Examination form.
CA_EDCOE Physical Exam Head Start Form
This is a sample of the California Physical Exam for Head Start/Early Headstart/State Preschool. ...
CA_EDCOE Well Child Exam Form
This is a sample of the California EDCOE Well Child Exam form. ...
CA_HHSA StayingHealthyAssessment 5 to 8 Years
This is a sample of the California HHSA - Staying Healthy Assessment 5-8 Years form (DHCS 7098 E). ...
CA_HHSA StayingHealthyAssessment 9 to 11 Years
This is a sample of the California HHSA - Staying Healthy Assessment 9-11 Years form (DHCS 7098 F). ...
CA_HHSA StayingHealthyAssessment 12 to 17 Years
This is a sample of the California HHSA - Staying Healthy Assessment 12 to 17 Years form (DHCS 7098 G). ...
CA_HHSA StayingHealthyAssessment Adult
This is a sample of the California HHSA - Staying Healthy Assessment Adult form (DHCS 7098 F). ...
CA_Immunization
This is a sample of the California
Pre-Kindergarten and School Immunization Record (CDPH 286). ...
CA_Report for Medical Examination for School Entry Form
This is a sample of the California Medical Examination for School Entry Report form. It is currently called the School Entry Health Exam Requirement form. There is a Spanish version of this form. ...
CO_Health Appraisal Form
This is a sample of the Colorado General Health Appraisal form. ...
CO_CHSAA Physical Examination Form
This is a sample of the Colorado Medical History (Part II) and Physical Examination (Part III) form. ...
CT_Health Assessment Record_Birth to 5 Form
This is a sample of the State of Connecticut Department of Education - Early Childhood Health Assessment Record (birth - 5 years) form. ...
CT_Authorization for the Administration of Medications by School, Child Care, and Youth Camp Personnel Form
This is a sample of the Connecticut Authorization for the Administration of Medications by School, Child Care, and Youth Camp Personnel form. ...
DE_School Physical Exam Form
This is a sample of the Delaware School Physical Examination form. ...
DE_Health Appraisal Form
This is a sample of the State of Delaware Department of Services for Children, Youth and Their Families Office of Child Care Licensing Child Health Appraisal Form (DOC. NO.37-06-10-01-01-01). ...
DE_Student Health - Adolescent Grades 7-12
This is a sample of the Delaware Student Health - Adolescent Grades 7-12 form. ...
FL_School Entry Health Exam Form
This is a sample of the State of Florida School Entry Health Exam form. ...
FL_Certification of Immunization
This is a sample of the State of Florida Certification of Immunization form. ...
FL_Department of Health WIC Program - Medical Documentation for Formula and Food Form
This is a sample of the Florida Department of Health WIC Program - Medical Documentation for Formula and Food form. ...
FL_Preparticipation Physical Evaluation
This is a sample of the State of Florida High School Athletic Association Preparticipation Physical Evaluation form. ...
FL_WellCare Authorization Request Form
This is a sample of the State of Florida WellCareAuthorization Request Form. ...
FL_WIC Referral Form
This is a sample of the State of Florida Medical Documentation for Formula and Food form. ...
GA_Form 3300 - Certificate of Vision, Hearing, Dental, and Nutrition Screening Form
This is a sample of the Georgia Department of Public Health Form 3300 - Certificate of Vision, Hearing, Dental, and Nutrition Screening. ...
GA_Certificate of Immunization GRITS
This is a sample of the State of Georgia Certification of Immunization form. ...
GA_Preparticipation Physical Evaluation Form
This is a sample of the State of Georgia Preparticipation Physical Evaluation form. ...
IL_Certificate of Child Health Examination Form
This is a sample of the State of Illinois Certificate of Child Health Examination form. ...
IL_HSA Preparticipation Exam Form
This is a sample of the Illinois HSA Preparticipation Exam form. ...
IL_ODLSS Physician's Request for Administration of Medication to Student
This is a sample of the Illinois ODLSS Physician's Request for Administration of Medication to Student. ...
IL_ODLSS Physician's Request for Student to Carry an EpiPen on Person
This is a sample of the Illinois ODLSS Physician's Request for Student to Carry an EpiPen on Person. ...
IL_ODLSS Physician's Request for Student to Carry Inhaler on Person
This is a sample of the Illinois ODLSS Physician's Request for Student to Carry Inhaler on Person. ...
IN_IHSAA Preparticipation Evaluation Form
This is a sample of the State of Indiana Preparticipation Physical Evaluation form. ...
IN_Child Care Health Record
This is a sample of the State of Indiana Health Care Program for Child Care Centers - Child Care Center Health Record form. ...
IA_Certificate of Immunization
This is a sample of the Iowa Department of Public Health - Certificate of Immunization form. ...
IA_IHSAA Preparticipation Exam Form
This is a sample of the Iowa Athletic Pre-Participation Physical Exam form. ...
KS_Preparticpation Evaluation Form
This is a sample of the Kansas Preparticipation Physical Evaluation form. ...
KS_Certificate of Immunizations (KCI)
This is a sample of the Kansas Certificate of Immunizations (KCI) form. ...
KY_Certificate of Immunization Status
This is a sample of the Commonwealth of Kentucky - Certificate of Immunization Status form. ...
KY_KHSAA Middle School Preparticipation Exam Form
This is a sample of the Kentucky KHSAA Middle School Preparticipation Exam Form. ...
KY_KHSAA Preparticipation Exam Form
This is a sample of the Kentucky KHSAA Preparticipation Exam Form. ...
KY_WIC Less Than 1 Year
This is a sample of the Kentucky WIC Program for Infants < 1 year, Certificate for Medical Necessity for Formula, and WIC Food Exceptions form. ...
LA_LHSAA Medical History Evaluation
This is a sample of the Louisiana LHSAA Medical History Evaluation form. ...
LA_Universal Certificate of Immunizations
This is a sample of the State of Louisiana Universal Certificate of Immunizations form. ...
MA_Department of Early Education and Care - Family Child Care Medical Form
This is a sample of the Massachusetts Department of Early Education and Care - Family Child Care Medical form. ...
MA_Health Care Providers Examination
This is a sample of the Massachusetts School Health Record - Health Care Provider's Examination form. ...
MD_Department of Health and Mental Hygiene Blood Lead Testing Certificate
This is a sample of the Maryland Department of Health and Mental Hygiene Blood Lead Testing Certificate form. ...
MD_Department of Health Immunization Certificate
This is a sample of the Maryland Department of Health Immunization Certificate form. ...
MD_MCPS SR6 2019
This is a sample of the Maryland Student Record Card 6 form. ...
MD_Medication Administration Authorization
This is a sample of the Maryland State School Medication Administration Authorization form. ...
MD_Pre-Participation Physical Evaluation History Form
This is a sample of the Maryland Pre-Participation Physical Evaluation History form. ...
MD_School and Child Health Assessment
This is a sample of the Maryland School and Child Health Assessment form. ...
MD_Uniform Consultation Referral Form
This is a sample of the Maryland Uniform Consultation Referral form. ...
ME_LeadcareII Lead Analysis Form
This is a sample of the Maine LeadCarell Blood Lead Analysis Reporting Fax form. ...
MI_Health Appraisal Form
This is a sample of the Michigan Health Appraisal form. ...
MI_MHSAA Preparticipation Exam Form
This is a sample of the Michigan Preparticipation Exam form. ...
MI_Preparticipation Physical Evaluation
This is a sample of the Michigan Preparticipation Physical Evaluation form. ...
MN_Blood Lead Report
This is a sample of the Minnesota MDH Blood Lead Report form. ...
MN_MSHSL Physical Form
This is a sample of the Minnesota 2016-2017 Sports Qualifying Physical History form. ...
MO_Child Medical Exam Infant Toddler PreSchool
This is a sample of the Missouri Child Medical Examination Report (Infant/Toddler/Pre-School) form. ...
MO_Preparticipation Exam form
This is a sample of the Missouri State Pre-Participation Physical Evaluation form. ...
MS_Certificate of Immunization Compliance
This is a sample of the Mississippi Form No 121: Certificate of Immunization Compliance. ...
MT_Preparticipation Exam Form
This is a sample of the Montana MHSA Athletic Preparticipation Physical Examination form. ...
NC_Blood Lead Analysis
This is a sample of the North Carolina Blood Lead Analysis form. ...
NC_Diet Order Form
This is a sample of the North Carolina Diet Order form. ...
NC_Health Assessment Form
This is a sample of the North Carolina Health Assessment Transmittal form. ...
NC_NCHSAA Preparticipation Exam Form
This is a sample of the North Carolina School Athletic Association Sport Preparticipation Examination Form (Approved for 2019-2020 School Year). ...
NC_WIC Child
This is a sample of the North Carolina WIC Program Medical Documentation, Child form. ...
NJ_Preparticipation Exam Form
This is a sample of the New Jersey Preparticipation Physical Exam form. ...
NJ_Universal Child Health Record
This is a sample of the New Jersey Universal Child Health Record form. ...
NJ_WIC 42
This is a sample of the New Jersey WIC Health Care Referral form. ...
NV_NIAA Preparticipation Exam Form_D
This is a sample of the Nevada NIAA Preparticipation Physical Evaluation form (Form D). ...
NYC_History Phys Exam Form
This is a sample of the New York City Preparticipation Physical Evaluation form. ...
NY_Child Health Exam CH205
This is a sample of the New York City Child & Adolescent Health Examination form. ...
NY_Health Certificate Appraisal Form
This is a sample of the New York Health Certificate Appraisal form. ...
NY_Medical Statement
This is a sample of the New York State Office of Children and Family Services Child in Care Medical Statement form. ...
NY_Required NYS School Health Examination Form
This is a sample of the New York State Required School Health Examination form. ...
NY_Sports Examination Form
This is a sample of the New York Sports Examination form. ...
OH_Child Medical Statement for Child Care
This is a sample of the Ohio Child Medical Statement for Child Care form. ...
OH_HSAA Preparticipation Exam Form
This is a sample of the Ohio High School Athletic Associatioin Preparticipation Physical Evaluation 2017-2018 form. ...
OK_OSSAA Preparticipation Exam Form
This is a sample of the Oklahoma Preparticipation Exam form. ...
OK_WIC Exception Request for Formula Food
This is a sample of the Oklahoma WIC Exception Request for Formula Food form. ...
PA_Allergy and Anaphylaxis Form
This is a sample of the Pennsylvania Allergy and Anaphylaxis form. ...
PA_Child Health Assessment
This is a sample of the Pennsylvania Child Health Assessment form. ...
PA_Child Health Report
This is a sample of the Pennsylvania Child Health Report form. ...
SC_Certificate of Immunization
This is a sample of the South Carolina Certificate of Immunization form. ...
TX_Preparticipation Exam Form
This is a sample of the Texas Preparticipation Exam form. ...
TN_TSSAA Clearance Form
This is a sample of the Tennessee TSSAA Clearance form. ...
TN_TSSAA Preparticipation Exam Form
This is a sample of the Tennessee TSSAA Preparticipation Exam form. ...
TX_Childhood Blood Lead Level Report
This is a sample of the Texas Childhood Blood Lead Level Report. ...
UT_DCFS Health Visit Report
This is a sample of the Utah DHS-DCFS Form 984 - Health Visit Report form. ...
UT_Preparticipation Exam Form
This is a sample of the Utah Preparticipation Exam form. ...
VA_Inhaler Authorization
This is a sample of the Commonwealth of Virginia Fairfax County Public Schools - Inhaler Authorization form. ...
VA_School Entrance Health Form
This is a sample of the Commonwealth of Virginia - School Entrance Health form. ...
WA_Certificate of Immunization Status_v1
This is a sample of the Washinton State Certificate of Immunization Status (CIS) Version 1. ...
WA_Certificate of Immunization Status_v2
This is a sample of the Washinton State Certificate of Immunization Status (CIS) Version 2. ...
WV_Child Health Assessment
This is a sample of the West Virginia Child Health Assessment form. ...
WV_SSAC Preparticipation Exam Form
This is a sample of the West Virginia Athletic Participation/Parental Consent/Physician's Certificate form. ...
WY_WIC Program Medical Documentation
This is a sample of the Wyoming WIC Program Medical Documentation form. ...
WY_WHSAA School Physical Examination
This is a sample of the Wyoming WHSAA School Physical Examination form. ...
AL_Alabama Medicaid Pharmacy Override Request
This is a sample of the Alabama Medicaid Pharmacy Override Request Form, Form 409. ...
AL_Medicaid Referral Form
This is a sample of the Alabama Medicaid Referral Form, Form 362. ...
AR_Medicaid Primarycare Referral Rev
This is a sample of the Division of Medical Services Arkansas Medicaid Primary Care Physican Managed Care Program Referral (DMS-2610). ...
AR_Occupational, Physical and Speech Therapy Referral for Medicaid
This is a sample of the Arkansas Occupational, Physical and Speech Therapy Referral for Medicaid (DMS 640). ...
CA_HHSA StayingHealthyAssessment 0 to 6 Months
This is a sample of the California HHSA - Staying Healthy Assessment 0-6 Months form (DHCS 7098 A). ...
CA_HHSA StayingHealthyAssessment 7 to 12 Months
This is a sample of the California HHSA - Staying Healthy Assessment 7-12 Months form (DHCS 7098 B). ...
CA_HHSA StayingHealthyAssessment 1 to 2 Years
This is a sample of the California HHSA - Staying Healthy Assessment 1-2 Years form (DHCS 7098 C). ...
CA_HHSA StayingHealthyAssessment 3 to 4 Years
This is a sample of the California HHSA - Staying Healthy Assessment 3-4 Years form (DHCS 7098 D). ...
NY_WIC Medical Referral Form
This is a sample of the New York State DOH WIC Medical Referral form. ...
PA_Private or School Physical Examination of School Age Student
This is a sample of the Pennsylvania Private or School Physical Examination form. ...
PA_Allergy and Anaphylaxis Medication Administration Form
This is a sample of the Pennsylvania Allergy and Anaphylaxis Medication Administration form (School year 2019-2020). ...
PA_PIAA Preparticipation Physical Exam
This is a sample of the PIAA Comprehensive Initial Pre-Participation Physical Evaluation form. ...
PA_Learners Permit Application
This is a sample of the Pennsylvania Non-Commercial Learner's Permit Application form. ...
PA_Special Olympics Application
This is a sample of the Pennsylvania Application For Athlete Participation in Special Olympics form. ...
SC_VFC Patient Eligibility Screening Record
This is a sample of the South Carolina VFC Patient Eligibility Screening Record form. ...
SC_Pre-Participation History & Health Assessment
This is a sample of the South Carolina Pre-Participation History & Health Assessment form. ...
TN_Certificate of Immunization
This is a sample of the Tennessee Certificate of Immunization. ...
TX_Austin AISD 2019-2020 Participation Form
This is a sample of the Austin AISD (2019-2020) Participation form. ...
TX_Girl Scouts of San Jacinto Council
This is a sample of the Texas Girl Scouts of San Jacinto Council form. ...
TX_Vaccine for Children Program English
This is a sample of the Texas Vaccines for Children (TVFC) Program form. ...
TX_Vaccine for Children Program Spanish
This is a sample of the Texas Vaccines for Children (TVFC) Program form. ...
TX_Immunization Registry Minor Consent Form
This is a sample of the Texas Immunization Registry Minor Consent form. ...
UT_Dept of Health Unified Health Appraisal
This is a sample of the Utah Department of Health Unified Health Appraisal form. ...
VA_Middle School Physical Form
This is a sample of Prince William County Middle Schools Athletic form. ...
VA_High School Athletic Participation Examination Form
This is a sample of the Virginia High School Athletic Participation/Parental Consent/Physical Examination form. ...
VA_Request for Special Food Prescription (WIC-395)
This is a sample of the Virginia Request for Special Food Prescription (WIC-395) form. ...
WY_WYHealth Care Management Referral Form
This is a sample of the WYHealth Care Management Referral form. ...
DE_Interscholastic Athletic Pre-Participation Physical Evaluation
This is a sample of the State of Delaware Interscholastic Athletic Association Pre-Participation Physical Evaluation form. ...