LIS

Virginia Law

Administrative Code

Creating a Report: Check the sections you'd like to appear in the report, then use the "Create Report" button at the bottom of the page to generate your report. Once the report is generated you'll then have the option to download it as a pdf, print or email the report.

Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 50. Amount, Duration, and Scope of Medical and Remedial Care Services
4/8/2026

FORMS (12VAC30-50).

Virginia Uniform Assessment Instrument, UAI, Virginia Long-Term Care Council (rev. 11/2018)

I.V. Therapy Implementation Form, DMAS-354 (eff. 6/1998)

Health Insurance Claim Form, Form HCFA-1500 (eff. 12/1990)

Certificate of Medical Necessity-Durable Medical Equipment and Supplies, DMAS-352 (rev. 7/2010)

Questionnaire to Assess an Applicant's Ability to Independently Manage Personal Attendant Services in the CD-PAS Waiver or DD Waiver, DMAS-95 Addendum (eff. 8/2005)

Comprehensive Outpatient Rehab Facility Participation Agreement (undated; filed 11/2015)

Rehabilitation Hospital Participation Agreement (undated; filed 11/2015)

Medical Necessity Assessment and Private Duty Nursing Service Authorization Form, DMAS 62 (rev. 7/2021)

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

As a service to the public, the Virginia Administrative Code is provided online by the Virginia General Assembly. We are unable to answer legal questions or respond to requests for legal advice, including application of law to specific fact. To understand and protect your legal rights, you should consult an attorney.