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  • This page, MassHealth All Provider Forms, is   offered by
  • MassHealth

MassHealth All Provider Forms

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90 Day Waiver Request Form, Open PDF file, 89.87 KB (English, PDF 89.87 KB)
Annual Attestation of Compliance: Employee Education about Medicaid False Claims, per Federal Deficit Reduction Act of 2005, Section 6032 [MFC-1] , Open PDF file, 47.33 KB (English, PDF 47.33 KB)
Annual Attestation of Compliance: Employee Education about Medicaid False Claims, per Federal Deficit Reduction Act of 2005, Section 6032 [MFC-1], Open DOCX file, 18.46 KB (English, DOCX 18.46 KB)
CARES Program Provider Certification Form, Open PDF file, 1.61 MB (English, PDF 1.61 MB)
CARES Program Provider Certification Form, Open DOCX file, 25.33 KB (English, DOCX 25.33 KB)
Certification of Treatment of Emergency Medical Condition [MHL-EMT], Open PDF file, 49.6 KB (English, PDF 49.6 KB)
Certification of Treatment of Emergency Medical Condition [MHL-EMT], Open DOC file, 36 KB (English, DOC 36 KB)
Duplicate Remittance Advice Request
Provider Enrollment Data Collection Form and Registration Instructions [POSC-HCBS], Open PDF file, 77.56 KB (English, PDF 77.56 KB)
Provider Enrollment Data Collection Form and Registration Instructions [POSC-HCBS], Open DOCX file, 35.5 KB (English, DOCX 35.5 KB)
Electronic Claims Waiver Request, Open PDF file, 63.97 KB (English, PDF 63.97 KB)
Electronic Funds Transfer Enrollment/Modification Form [EFT-1], Open PDF file, 652.05 KB (English, PDF 652.05 KB)
Electronic Funds Transfer Enrollment/Modification Form [EFT-1], Open DOCX file, 28.5 KB (English, DOCX 28.5 KB)
Electronic Remittance Advice Enrollment/Modification Form [ERA-1], Open PDF file, 299.28 KB (English, PDF 299.28 KB)
Electronic Remittance Advice Enrollment/Modification Form [ERA-1], Open DOCX file, 23.95 KB (English, DOCX 23.95 KB)
Federally Required Disclosures Form for Individual Practitioners (PE-FRD-IN), Open PDF file, 148.24 KB (English, PDF 148.24 KB)
Federally Required Disclosures Form for Individual Practitioners (PE-FRD-IN), Open DOC file, 41 KB (English, DOC 41 KB)
Managed-Care Entity (MCE) Retroactive Recoupment [MCE-RR], Open XLS file, 25 KB (English, XLS 25 KB)
Massachusetts Substitute W-9 Form, Open PDF file, 346.7 KB (English, PDF 346.7 KB)
Massachusetts Substitute W-9 Form, Open DOCX file, 37.84 KB (English, DOCX 37.84 KB)
Tips for Completing the Massachusetts Substitute W-9 Form , Open PDF file, 126.91 KB (English, PDF 126.91 KB)
Tips for Completing the Massachusetts Substitute W-9 Form, Open DOCX file, 18.48 KB (English, DOCX 18.48 KB)
MassHealth Health Coverage Mail/Fax Cover Sheet, Open PDF file, 279.71 KB (English, PDF 279.71 KB)
MassHealth Health Coverage Mail/Fax Cover Sheet, Open DOCX file, 310.57 KB (English, DOCX 310.57 KB)
MassHealth Residency Program Integrity Referral Form, Open PDF file, 104.04 KB (English, PDF 104.04 KB)
MassHealth Residency Program Integrity Referral Form, Open DOC file, 99.5 KB (English, DOC 99.5 KB)
Provider Overpayment Disclosure Form, Open PDF file, 94.22 KB (English, PDF 94.22 KB)
Provider Overpayment Disclosure Form, Open DOCX file, 44.61 KB (English, DOCX 44.61 KB)
Request for MassHealth Forms [RMF] , Open PDF file, 104.71 KB (English, PDF 104.71 KB)
Request for MassHealth Forms [RMF], Open DOC file, 64 KB (English, DOC 64 KB)
Third Party Carrier Code Request [TPCCR] , Open PDF file, 80.22 KB (English, PDF 80.22 KB)
Third Party Carrier Code Request [TPCCR] , Open TXT file, 1.2 KB (English, TXT 1.2 KB)
Third Party Liability Indicator, Open PDF file, 59.07 KB (English, PDF 59.07 KB)
Third Party Liability Indicator, Open DOCX file, 31.86 KB (English, DOCX 31.86 KB)
MassHealth Trading Partner Agreement, Open PDF file, 172.69 KB (English, PDF 172.69 KB)
Información sobre la responsabilidad de terceros, Open PDF file, 58.34 KB (English, PDF 58.34 KB)
Información sobre la responsabilidad de terceros, Open DOCX file, 32.37 KB (English, DOCX 32.37 KB)
Void Request Form [VR-1] , Open PDF file, 51.87 KB (English, PDF 51.87 KB)
Void Request Form [VR-1], Open DOCX file, 15.28 KB (English, DOCX 15.28 KB)

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