ScreenWise Provider Forms

Operational Documents

• ScreenWise Program Operations Manual
• ScreenWise Data Reporting Requirements
• Secure Portal Instructions(required for all submissions)
  
• 2024 EOB and PDR Schedule
• Provider Contact Update Form 
  

Enrollment and Results Forms

 Forms Valid 12/2024-Current

• ScreenWise Patient Enrollment Form (English)
  
• ScreenWise Patient Enrollment Form (Russian)
  
• ScreenWise Patient Enrollment Form (Korean)
  
• ScreenWise Patient Enrollment Form (Chinese)
  
• ScreenWise Patient Enrollment Form (Spanish)
  
• ScreenWise Patient Enrollment Form (Vietnamese)
  
• ScreenWise Results Form 
  

• ScreenWise Final Outcome Form
  

Optional Forms

Referral Form
This document is not required but can be used as a tool to refer ScreenWise patients for services. 

Request for a Clinical Exception
If you have a recommended procedure that is not on our CPT code list, you can use this form to request an exception.

All forms are in PDF format.