Online Forms | Health and Human Services North Dakota

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Below is a list of common fillable forms used by the Medical Services Division. Other state forms can be found on the state's e-forms website.

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Service Authorizations

SFN 292 - Request for Service Authorization for Vision Services

SFN 481 - Service Limits Service Authorization Request

SFN 511 - Medical Procedure/Device Service Authorization Request

SFN 769 - Request for Service Authorization for Out-of-State Services

SFN 1106 - Medication Therapy Management (MTM) Service Authorization Request

Group Authorization - Basic Care (PDF)

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Agreements

SFN 308 - Medicaid and Basic Care Assistance Programs Provider Agreement

SFN 615 - Medicaid Program Provider Agreement

SFN 1169 - Pharmacy Agreement/Medical Assistance Program

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MMIS/Claims/Reimbursement

SFN 177 - MMIS Attachment Cover Sheet

SFN 447 - Exemption for Submitting Electronic Claims

SFN 583 - Electronic Remittance Advice (835) Enrollment

SFN 661 - Electronic Funds Transfer (EFT) Form

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Certifications

SFN 606 - Medicaid Out of State Services Certification

SFN 614 - Physician Certification for Sterilization and Recipient Acknowledgement of Sterility

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Consents & Authorization to Disclose Information

HHS-687 - Consent for Sterilization (required federal form)

SFN 1059 - Authorization to Disclose Information

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Transportation Forms

SFN 170 - Taxi Transportation Voucher

SFN 249 - Medical Certificate of Transportation Services

SFN 294 - Non-Emergency Medical Transportation Authorization

SFN 296 - Non-Emergency Medical Transportation Trip Ticket

SFN 1731 - Medical Travel/Lodging Billing Form

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Miscellaneous Forms

SFN 662 - Personal Care Services Plan

SFN 705 - Health Tracks Appointment Slip

SFN 710 - Health Tracks Referral and Request for Information

SFN 871 - ND Health Tracks Screening Result

SFN 1105 - Medication Therapy Management (MTM) Provider Enrollment Application

SFN 1110 - Medication Therapy Management (MTM) Missed Appointment

SFN 1168 - Ownership/Controlling Interest and Conviction Information