Open PDF file, 37.96 KB,
90-Day Waiver Request Form [90-DWR]
(English, PDF 37.96 KB)
Open DOC file, 34 KB,
90-Day Waiver Request Form [90-DWR]
(English, DOC 34 KB)
Open PDF file, 2.15 MB,
CARES Program Provider Certification Form
(English, PDF 2.15 MB)
Open DOCX file, 24.57 KB,
CARES Program Provider Certification Form
(English, DOCX 24.57 KB)
Open PDF file, 49.6 KB,
Certification of Treatment of Emergency Medical Condition [MHL-EMT]
(English, PDF 49.6 KB)
Open PDF file, 131.48 KB,
Duplicate Remittance Advice Request
(English, PDF 131.48 KB)
Open DOCX file, 21.51 KB,
Duplicate Remittance Advice Request
(English, DOCX 21.51 KB)
Open PDF file, 44.5 KB,
Electronic Claims Waiver Request
(English, PDF 44.5 KB)
Open DOC file, 39.5 KB,
Electronic Claims Waiver Request
(English, DOC 39.5 KB)
Open PDF file, 652.05 KB,
Electronic Funds Transfer Enrollment/Modification Form [EFT-1]
(English, PDF 652.05 KB)
Open DOCX file, 28.5 KB,
Electronic Funds Transfer Enrollment/Modification Form [EFT-1]
(English, DOCX 28.5 KB)
Open PDF file, 304.75 KB,
Electronic Remittance Advice Enrollment/Modification Form [ERA-1]
(English, PDF 304.75 KB)
Open DOCX file, 23.95 KB,
Electronic Remittance Advice Enrollment/Modification Form [ERA-1]
(English, DOCX 23.95 KB)
Open XLS file, 25 KB,
Managed-Care Entity (MCE) Retroactive Recoupment [MCE-RR]
(English, XLS 25 KB)
Open PDF file, 346.7 KB,
Massachusetts Substitute W-9 Form
(English, PDF 346.7 KB)
Open DOCX file, 37.84 KB,
Massachusetts Substitute W-9 Form
(English, DOCX 37.84 KB)
Open PDF file, 126.91 KB,
Tips for Completing the Massachusetts Substitute W-9 Form
(English, PDF 126.91 KB)
Open DOCX file, 18.48 KB,
Tips for Completing the Massachusetts Substitute W-9 Form
(English, DOCX 18.48 KB)
Open PDF file, 279.71 KB,
MassHealth Health Coverage Mail/Fax Cover Sheet
(English, PDF 279.71 KB)
Open DOCX file, 310.57 KB,
MassHealth Health Coverage Mail/Fax Cover Sheet
(English, DOCX 310.57 KB)
Open PDF file, 104.04 KB,
MassHealth Residency Program Integrity Referral Form
(English, PDF 104.04 KB)
Open DOC file, 99.5 KB,
MassHealth Residency Program Integrity Referral Form
(English, DOC 99.5 KB)
Open PDF file, 94.22 KB,
Provider Overpayment Disclosure Form
(English, PDF 94.22 KB)
Open DOCX file, 44.61 KB,
Provider Overpayment Disclosure Form
(English, DOCX 44.61 KB)
Open PDF file, 104.71 KB,
Request for MassHealth Forms [RMF]
(English, PDF 104.71 KB)
Open DOC file, 64 KB,
Request for MassHealth Forms [RMF]
(English, DOC 64 KB)
Open PDF file, 80.22 KB,
Third Party Carrier Code Request [TPCCR]
(English, PDF 80.22 KB)
Open TXT file, 1.2 KB,
Third Party Carrier Code Request [TPCCR]
(English, TXT 1.2 KB)
Open PDF file, 52.08 KB,
Third Party Liability Indicator
(English, PDF 52.08 KB)
Open DOCX file, 43.36 KB,
Third Party Liability Indicator
(English, DOCX 43.36 KB)
Open PDF file, 202.43 KB,
MassHealth Trading Partner Agreement
(English, PDF 202.43 KB)
Open DOCX file, 48.07 KB,
MassHealth Trading Partner Agreement
(English, DOCX 48.07 KB)
Open PDF file, 59.97 KB,
Información sobre la responsabilidad de terceros
(English, PDF 59.97 KB)
Open DOCX file, 36.6 KB,
Información sobre la responsabilidad de terceros
(English, DOCX 36.6 KB)
Open PDF file, 51.87 KB,
Void Request Form [VR-1]
(English, PDF 51.87 KB)
Open DOCX file, 15.28 KB,
Void Request Form [VR-1]
(English, DOCX 15.28 KB)