Provider forms and references

Idaho Provider complaint online form

State forms

To access Idaho’s Bureau of Long Term Care forms, please visit their website.open_in_new

First time providers will need to sign up for access. If you need assistance, please contact the Bureau of Long Term Care at BLTCCentral@dhw.idaho.gov.

Forms available include (but are not limited to):

• Agency Change
• Exception Request Form and Instructions
• Family Personal Care Service Request Form
• Fiscal intermediary MOU
• Non-Use of Services Form
• Notification of Change
• RESHAB Verification for Intense Review Form
• RN Supervisory Visit Form
• Service and Provider Choice
• Significant Change
• Supplemental Service Request Form

Submit a pre-service appeal or grievance