MassHealth Provider Forms

All Providers

• Data Collection Form [POSC-DC] (PDF) 
• Electronic Claims Waiver Request 
• EFT/Direct Deposit Application [EFT-1] (PDF)  file size 1MB
• False Claims Education Compliance Form [MFC-1] (PDF) 
• Federally Required Disclosure Form [PE-FRD] 
• MassHealth Duplicate Remittance Advice Request Form [DUP-RA] (PDF) 
• MassHealth Cover Sheet Guide 
• MassHealth Cover Sheet 
• Massachusetts Substitute W-9 Form (PDF) 
• My Account Page [MAP] Flyer (PDF) 
• National Provider Identifier (NPI) Supplement (PDF) 
• Provider Change of Address Form [CAD]
• Provider Overpayment Disclosure Form 
• Remittance Advice Request Form [R-RA] (PDF) 
• Request for MassHealth Forms [RMF] (PDF) 
•  Request For Member Education In-Service Form
• Third Party Carrier Code Request [TPCCR] (PDF) 
• Third Party Liability Indicator [TPLI-MH] (PDF) 
• Tips for Completing the Massachusetts Substitute W-9 Form (PDF)  file size 1MB
• TPL Attachment Form 
• TPL Exception Form 
• Trading Partner Agreement [TPA] (PDF)  file size 1MB
• Void Request Form [VR-1] (PDF) 
• 90-Day Waiver Request Form [90-DWR] (PDF) 

Community Health Centers

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

Dental Providers

• Handicapping Labio-Lingual Deviations Form (The HLD Index No. 4) [DEN-HLD] 

Durable Medical Goods

• Durable Medical Equipment and Medical Supplies General Prescription and Medical Necessity Review Form (PDF) 
• Letter of Intent [LOI-DME] (PDF) 
• Personal Emergency Response System (PERS) General Prescription Form [PERS-GPF] (PDF) 

Forms Used by Multiple Provider Types

• Billing Guidelines for MassHealth Physicians and Mid-level Providers [EPSDT-BG] (PDF) 
• Certification for Payable Abortion [CPA-2] (PDF) 
• HIV Resistance Testing [HIV-RTR] (PDF) 
• Hysterectomy Information Form [HI-1] (PDF) 
• MassHealth Community Services Critical Incident Report Form [CIRF] 
• MassHealth Provider Contract for Individuals 
• Medical Necessity Review Form for Absorbent Products [MNR-AP] (PDF) 
• Medical Necessity Review Form for Ambulatory Infusion (Insulin Pumps) 
• Medical Necessity Review Form for Enteral Nutrition Products (PDF) 
• Medical Necessity Review Form for Hospital Beds (PDF) 
• Medical Necessity Review Form for Support Surfaces [MNR-SS] (PDF) 
• PCC Plan Handbook (PDF) 
• PCC Plan Contract Fourth Amended and Restated (PDF) 
• PCC Enhanced Fee Codes as of 01/01/2011 (PDF) 
• Preadmission Screening Form (Acute) [PAS-A] (PDF) 
• Preadmission Screening Form (Chronic Rehab) [PAS-CR] (PDF) 
• Primary Care Clinician Referral Form [PCC-RF] (PDF) 
• Prior Authorization Request [PA-1] (PDF) 
• Provider Contract for Entities (GEN-16) 
• Request and Justification for Therapy Services [THP-2] (PDF) 
• Sterilization Consent Form Ages 18-20 [CS-18] (PDF) 
• Sterilization Consent Form Ages 18-20 Spanish [CS-18S] (PDF) 
• Sterilization Consent Form Ages 21 and Older [CS-21] (PDF) 
• Sterilization Consent Form Ages 21 and Older Spanish [CS-21S](PDF) 
• Vision Care Material Order Form [VIS-1] 

Home Health Agency

• Homebound Assessment Form (HBA) 
• Home Health Coverage Determination Form [HHCD-1] (PDF) 
• MassHealth Aging Services Access Point ASAP Referral Form [HHA-004] (PDF)  file size 1MB

Hospice

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

Hospitals

• Notification of Birth (NOB-1) 

Independent Nurse

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

Indian Health Services

• Provider Contract for Indian Health Services (GEN-17) 

Local Public Health Departments or Public School Districts

• Flu Vaccine Program Provider Contract  file size 1MB

Long Term Care

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

Long Term Care - Nursing Facility

• Nursing Facility Census Data Collection Form [NF-CDCF] (PDF) 
• Nursing Facility Pay for Performance (NF P4P) Program Application Form [NF-P4P-APP] 
• Nursing-Facility Services Clinical Eligibility [NF-AIH-ADM-O (Rev. 09/09)] (PDF) 
• Level I Preadmission Screening [PAS-1] (PDF) 
• Notice of Nursing Facility Residents' Rights [LTC-013] (PDF) 
• Nursing Facility Provider Contract (CON-NF) (PDF) 

Long Term Care - Community

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

Orthotics

• MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Therapeutic Shoes, Inserts, and Modifications [ORT-D] (PDF) 
• MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Foot Orthoses, Footwear, and Modifications [ORT-ND] (PDF) 

Outpatient Hospitals

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

Personal Care

• Consumer Agreement for PCA Fiscal Intermediary Services [PCA-3] (PDF) 
• Consumer Assessment to Manage PCA Services [PCA-CA-1] (PDF) 
• MassHealth Application for PCA Services [PCA-1] (PDF) 
• MassHealth Evaluation for Personal Care Attendant (PCA) Services [PCA-2] (PDF) 
• PCA Prior Authorization Adjustment Form [PCA-PAAF-1] (PDF) 
• Personal Care Attendant Reevaluation Form [PCA-R] (PDF) 
• Personal Care Attendant Signature Form (English and Spanish) [PCA-S] (PDF) 
• Personal Care Attendant PCA Service Agreement [PCA-SA-1] (Eng PDF),  | Span PDF 
• Review of Consumer Assessment to Manage PCA Services [PCA-RCA-1] (PDF) 
• Standard Documentation to Include with a Prior Authorization Request for Personal Care Attendant (PCA) Services [PCA-SD] (PDF) 

Pharmacy

• POPS Billing Guide (PDF) 
• Prior Authorization Forms for Pharmacy Services

Physician

• Physician Certification and Attestation Form for ACA Section 1202 Rates for Physicians Who Provide Primary Care Services 

QMB-Only Providers

• Special Conditions: QMB-Only Provders (PDF) 

Rest Home

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

Transportation

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

 

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This information is provided by MassHealth.