MassHealth Provider Forms

All Providers

• MassHealth Duplicate Remittance Advice Request Form [DUP-RA] (PDF)| RTF
• EFT/Direct Deposit Application [EFT-1] (PDF)| RTF
• False Claims Education Compliance Form [MFC-1] (PDF) | TEXT 
• Health Safety Net Fax Cover Sheet [HSN-FC] (PDF) | TEXT   
• Remittance Advice Request Form [R-RA] (PDF) | TEXT 
• Request for MassHealth Forms [RMF] (PDF)| RTF
• Third Party Liability Indicator [TPLI] (PDF)| RTF
• TPL Claim Bundled/Unbundled Form [TPL-B-UB] (PDF) | TEXT
• TPL Exception Form (TPL-EF) (PDF) | TEXT
• Trading Partner Agreement [TPA] (PDF)| RTF
• Void Request Form [VR-1] (PDF)| TEXT
• Massachusetts Substitute W-9 Form (PDF) | RTF
• Tips for Completing the Massachusetts Substitute W-9 Form (PDF) | RTF 
• 90-Day Waiver Request Form [90-DWR] (PDF) | TEXT 

Community Health Centers

• Application for Community Health Centers Participating in 340B Drug-Pricing Program for MassHealth Members [PHM-340B-1] (PDF)| TEXT

Durable Medical Goods

• Documentation of Need for Durable Medical Equipment and Supplies General Prescription [DME-001] (PDF)| RTF
• Personal Emergency Response System (PERS) General Prescription Form [PERS-GPF] (PDF) | TEXT

Forms Used by Multiple Provider Types

• Anticonvulsant Prior Authorization Request [PA-18] (PDF) | TEXT
• Antidepressant Prior Authorization Request [PA-13] (PDF) | TEXT
• Antipsychotic Prior Authorization Request [PA-19] (PDF) | RTF
• Billing Guidelines for MassHealth Physicians and Mid-level Providers [EPSDT-BG] (PDF) | TEXT
• Brand-Name Drug  Use this form when requesting prior authorization for any other brand-name drug when there is an FDA "A"-rated generic available. Prior Authorization Request [PA-5] (PDF) | RTF
• Certification for Payable Abortion [CPA-2] (PDF) | RTF
• Drug  Use this form when requesting prior authorization for any drug. Prior Authorization Request [PA-2] (PDF) | RTF
• Erythropoietin Prior Authorization Request [PA-8] (PDF) | RTF
• Forteo Prior Authorization Request [PA-21] (PDF) | RTF
• Fuzeon Prior Authorization Request [PA-3] (PDF) | RTF
• Growth Hormone Adult Prior Authorization Request  PA-15] (PDF) | TEXT
• Growth Hormone Pediatric Prior Authorization Request [PA-16] (PDF) | TEXT
• Guidelines for Medical Necessity Determination for Absorbent Products [MG-AP] (PDF) | RTF
• Guidelines for Medical Necessity Determination for Enteral Nutrition Products [MG-EN] (PDF) | RTF
• Guidelines for Medical Necessity Determination for Support Surfaces [MG-SS] (PDF) | RTF
• Request and Justification for Therapy Services [THP-2] (PDF) | RTF
• Immune Globulin Intravenous IGIV Prior Authorization Request [PA-17] (PDF)| TEXT
• HIV Resistance Testing [HIV-RTR] (PDF) | RTF
• Hypnotics Prior Authorization Request [PA-11] (PDF) | TEXT
• Hysterectomy Information Form Prior Authorization Request [HI-1] (PDF) | RTF
• Medical Necessity Review Form for Absorbent Products [MNR-AP] (PDF) | RTF
• Medical Necessity Review Form for Enteral Nutrition Products [MNR-ENP] (PDF)| RTF
• Medical Necessity Review Form for Support Surfaces [MNR-SS] (PDF) | RTF
• Narcotic Prior Authorization Request [PA-12] (PDF) | TEXT
• Nonsteroidal Anti-Inflammatory Drugs NSAID Prior Authorization Request [PA-7] (PDF) | RTF
• PCC Plan Handbook (PDF) | TEXT
• Preadmission Screening Form (Acute) [PAS-A] (PDF) | TEXT
• Preadmission Screening Form (Chronic Rehab) [PAS-CR] (PDF) | TEXT
• Primary Care Clinician Referral Form [PCC-RF] (PDF) | RTF  
• Prior Authorization Request [PA-1] (PDF) | TEXT
• Proton Pump Inhibitor Prior Authorization Request [PA-4] (PDF) | TEXT
• Provider Agreement (short form) [GEN-015] (PDF) | TEXT
  • This form is to be used by the following provider types:  Physicians, Optometrists, Opticians, Ocularists, Psychologists, Podiatrists, Therapists, Nurse Midwives, Chiropractors, Nurse Practitioners, Early Intervention, Pharmacy, Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment, Orthotics, Prosthetics, Hearing Instrument Specialists, Independent Diagnostic Testing Facilities, Independent Labs, Independent Nurses, Transportation, Audiologists, Home Health Agencies, Adult Day Health, Adult Foster Care, Group Adult Foster Care, Day Habilitation, Transitional Living, Home Care Corporations, Hospice, and Group Practice Organizations.
    
• Provider Agreement (long form) [GEN-016] (PDF) | TEXT
  • This form is to be used by the following provider types:  Community Health Centers, Family Planning Agencies, Abortion/Sterilization Clinics, Speech and Hearing Clinics, Rehabilitation Clinics, Renal Dialysis Clinics, Mental Health Centers, Substance Abuse Treatment Centers, Psychiatric Day Treatment Centers, Hospitals, Hospital Licensed Health Centers, and Freestanding Ambulatory Surgery Centers. 
• Special Program Provider Registration [SPP-R] Form (PDF) | TEXT
• Special Program Provider Contract [SPP-C] (PDF) | TEXT 
• Statin Prior Authorization Request [PA-9] (PDF) | TEXT
• Sterilization Consent Form Ages 18-20 [CS-18] (PDF) | RTF
• Sterilization Consent Form Ages 18-20 Spanish [CS-18S] (PDF) | RTF
• Sterilization Consent Form Ages 21 and Older [CS-21] (PDF) | RTF
• Sterilization Consent Form Ages 21 and Older Spanish [CS-21S](PDF) | RTF
• Strattera Prior Authorization Request [PA-20] (PDF) | TEXT
• Triptan Prior Authorization Request [PA-10] (PDF) | TEXT
• TPL Exception Form for Nursing Facilities and All Inpatient Hospitals (TPL-EF-NH-IH) (PDF) | TEXT

Home Health Agency

• MassHealth Aging Services Access Point ASAP Referral Form [HHA-004] (PDF)| RTF
• Home Health Coverage Determination Form [HHCD-1] (PDF) | TEXT 
• TPL Exception Form for Home Health Agencies (TPL-EF-HHA) | TEXT

Hospice

• Hospice Election Form [HOS-1] (PDF) | TEXT

Independent Nurse

• Request and Justification for Continuous Skilled Nursing Services [PA-PDN-1] (PDF) | RTF

Long Term Care

• A Guide to the Program of All-inclusive Care for Elderly (PACE) MassHealth Members (PDF) | TEXT
• A Guide to the Senior Care Options (SCO) Program for MassHealth Providers (PDF) | TEXT
• Status Change for Members in a Nursing Facility or Chronic Disease and Rehabilitation Inpatient Hospital [SC-1] (PDF) | TEXT

Long Term Care - Nursing Facility

• Nursing-Facility Services Clinical Eligibility [NF-AIH-ADM-O (Rev. 09/09)] (PDF) | TEXT 
• Bank Reconciliation for Members' Personal Needs Account [PNA-2] (PDF) | TEXT
• Level I Preadmission Screening [PAS-1] (PDF) | RTF
• Notice of Nursing Facility Residents' Rights [LTC-013] (PDF) | RTF
• Statement of Members' Personal Needs Account [PNA-1] (PDF) | TEXT
• Nursing Facility Provider Contract (CON-NF) (PDF) | TEXT

Long Term Care - Community

• Minimum Data Set - Home Care MDS-HC Version 2.0 (PDF) | TEXT
• Physician Summary Form [PSF-1] (PDF) | TEXT

Orthotics

• Shoe Medical Necessity Form [ORT-1] (PDF) | TEXT

Outpatient Hospitals

• Application for Outpatient Departments Participating in 340B Drug-Pricing Program for MassHealth Members [PHM-340B-2] (PDF) | TEXT

Personal Care 

• Consumer Agreement for PCA Fiscal Intermediary Services [PCA-3] (PDF) | TEXT
• Consumer Assessment to Manage PCA Services [PCA-CA-1] (PDF) | TEXT
• MassHealth Application for PCA Services [PCA-1] (PDF) | TEXT
• MassHealth Evaluation for Personal Care Attendant PCA Services [PCA-2] (PDF) | TEXT
• PCA Prior Authorization Adjustment Form [PCA-PAAF-1] (PDF) | TEXT
• Personal Care Attendant Signature Form [PCA-S] (PDF) | TEXT
• Personal Care Attendant PCA Service Agreement [PCA-SA-1] (Eng PDF), | Eng TEXT | Span PDF | Span TEXT
• Review of Consumer Assessment to Manage PCA Services [PCA-RCA-1] (PDF) | TEXT

Pharmacy

• POPS Billing Guide (PDF) | RTF

QMB-Only Providers

• Special Conditions: QMB-Only Provders (PDF)

Rest Home

• Status Change for Residents in a Rest Home [SC-1-RH] Form (PDF) | TEXT

Transportation

• Ambulance Medical Necessity [GEN-004] (PDF) | RTF

Vision Care

• Vision Care Material Order Form [VIS-1] (PDF) | TEXT