Document Type |
Form No. |
Form Name |
Instrument File |
URL |
Available Electronically? |
Can Be Submitted Electronically? |
Electronic Capability |
Form and Instruction |
Attachment 29 |
Attachment 29 –HC Access to Care Section
|
Attachment 29 HC Access to Care Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 30 |
Attachment 30 – HC Condition Enumeration Section
|
Attachment 30 HC Event Enumeration Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 31 |
Attachment 31 – Attachment 31 HC Assets Section.
|
Attachment 31 HC Assets Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 32 |
Attachment 32 – Attachment 32 HC Calendar Section
|
Attachment 32 HC Calendar Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 33 |
Attachment 33 Additional healthcare Section
|
Attachment 33 Additional healthcare Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 34 |
Attachment 34 HC Closing Section
|
Attachment 34 HC Closing Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 35 |
Attachment 35 HC Start_Restart
|
Attachment 35 HC Start_Restart Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 36 |
Attachment 36 HC Charge Payment Section
|
Attachment 36 HC Charge Payment Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 37 |
Attachment 37 HC Flat Fee Section
|
Attachment 37 HC Flat Fee Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 38 |
Attachment 38 – HC Child Preventive Health Supplement Section
|
Attachment 38 Child Preventive Health Supplement Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 39 |
Attachment 39 – HC Institutional Care Section
|
Attachment 39 HC Institutional Care Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 40 |
Attachment 40 – HC Dental Care Section
|
Attachment 40 HC Dental Care Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 41 |
Attachment 41 – HC Event Driver Section
|
Attachment 41 HC Event Driver Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 42 |
Attachment 42 – HC Employment (EM) Section
|
Attachment 42 HC Employment (EM) Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 43 |
Attachment 43 – HC Review of Employment Information (RJ) Section
|
Attachment 43 HC Review of Employment Information (RJ) Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 44 |
Attachment 44 – HC Employment Driver (OE) Section
|
Attachment 44 HC Employment Driver (OE) Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 45 |
Attachment 45 – HC Employment Wage (EW) Section
|
Attachment 45 Employment Wage (EW) Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 46 |
Attachment 46 – HC Emergency Room Section
|
Attachment 46 Emergency Room Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 47 |
Attachment 47 Event Roster Section
|
Attachment 47 Event Roster Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 48 |
Attachment 48 Health Status Section
|
Attachment 48 Health Status Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 49 |
Attachment 49 HC Help Text
|
Attachment 49 HC Help Text.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 50 |
Attachment 50 Home Health Section
|
Attachment 50 Home Health Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 51 |
Attachment 51 Health Insurance (HX) Section
|
Attachment 51 Health Insurance (HX) Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 52 HC |
Attachment 52 HC Private Health Insurance Detail (HP) Section
|
Attachment 52 HC Private Health Insurance Detail (HP) Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 53 |
Attachment 53 HC Time Covered Detail (HQ) Section
|
Attachment 53 HC Time Covered Detail (HQ) Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 54 |
Attachment 54 HC Managed Care (MC) Section
|
Attachment 54 HC Managed Care (MC) Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 55 |
Attachment 55 HC Old Employment Health Insurance (OE) Section
|
Attachment 55 HC Old Employment Health Insurance (OE) Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 56 |
Attachment 56 HC Old Public Related Insurance (PR) Section
|
Attachment 56 HC Old Public Related Insurance (PR) Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 57 |
Attachment 57 HC Hospital Stay Section
|
Attachment 57 HC Hospital Stay Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 58 |
Attachment 58 HC Income Section
|
Attachment 58 HC Income Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 59 |
Attachment 59 HC Medical Provider Section
|
Attachment 59 HC Medical Provider Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 60 |
Attachment 60 HC Other Medical Expense Section
|
Attachment 60 HC Other Medical Expense Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 61 |
Attachment 61 HC Outpatient Department Section
|
Attachment 61 HC Outpatient Department Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 62 |
Attachment 62 HC Quality Supplement Section
|
Attachment 62 HC Quality Supplement Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 63 |
Attachment 63 HC Respondent Forms Section
|
Attachment 63 HC Respondent Forms Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 64 |
Attachment 64 HC Priority Conditions Enumeration Section
|
Attachment 64 HC Priority Conditions Enumeration Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 65 |
Attachment 65 HC Prescribed Medicines Section
|
Attachment 65 HC Prescribed Medicines Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 66 |
Attachment 66 HC Provider Probes Section
|
Attachment 66 HC Provider Probes Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 67 |
Attachment 67 HC Provider Roster Section
|
Attachment 67 HC Provider Roster Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 68 |
Attachment 68 HC Reenumeration Subsection
|
Attachment 68 HC Reenumeration Subsection A.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 69 |
Attachment 69 HC Reenumeration Subsection B
|
Attachment 69 HC Reenumeration Subsection B.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 70 |
Attachment 70 HC RU Information Screener
|
Attachment 70 HC RU Information Screener.docx
|
|
Yes |
Yes |
Fillable Fileable |
Form and Instruction |
Attachment 71 |
Attachment 71 HC Event Follow Up Section
|
Attachment 71 HC Event Follow Up Section.pdf
|
|
Yes |
Yes |
Fillable Fileable |