Please complete all of Sections 1, 2, and 3. Fields with * are required.

 

1. Provider/Submitter Information This section may be completed using a group-practice organization provider number or a billing intermediary submitter number.

Enter the contact information for the provider or submitter for whom you are requesting account management access.
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2. Type of Request Check the appropriate option to indicate the reason for completing and submitting this form.

New account Add user(s) Change user access Deactivate user(s)

3. User Information List all persons who should be given access to the provider's or submitter's account. Specify the access type for each user. Once the account has been created, a username and password will be sent in two separate emails to each user listed below.

Access Types: Access type PT-1 gives the user the option to complete and submit Prescription for Transportation requests online. Access type Publications allows the user to order MassHealth publications online.

User No.1
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User No.2
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User No.3
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User No.4
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User No.5
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You will be contacted by MassHealth once your request has been completed. No further action is required from you.

 


This information is provided by MassHealth.