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.

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