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MassHealth Provider Forms by Provider Type A - D

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Adult Day Health

Open PDF file, 56.96 KB,  Adult Day Health Primary Care Provider Order Form (English, PDF 56.96 KB)
Open DOCX file, 36.96 KB,  Adult Day Health Primary Care Provider Order Form (English, DOCX 36.96 KB)
Open PDF file, 110.3 KB,  MassHealth Adult Day Health (ADH) Provider Supplemental Payment Request Form (English, PDF 110.3 KB)
Open DOCX file, 24.88 KB,  MassHealth Adult Day Health (ADH) Provider Supplemental Payment Request Form (English, DOCX 24.88 KB)

Adult Foster Care

Open PDF file, 182.58 KB,  MassHealth Adult Foster Care Member Intake/Transfer Form (English, PDF 182.58 KB)
Open DOCX file, 40.97 KB,  MassHealth Adult Foster Care Member Intake/Transfer Form (English, DOCX 40.97 KB)
Open PDF file, 115.89 KB,  MassHealth Adult Foster Care Primary Care Provider (PCP) Order Form (English, PDF 115.89 KB)
Open DOCX file, 20.79 KB,  MassHealth Adult Foster Care Primary Care Provider (PCP) Order Form (English, DOCX 20.79 KB)

All Provider

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, 47.33 KB,  Annual Attestation of Compliance: Employee Education about Medicaid False Claims, per Federal Deficit Reduction Act of 2005, Section 6032 [MFC-1] (English, PDF 47.33 KB)
Open DOCX file, 18.46 KB,  Annual Attestation of Compliance: Employee Education about Medicaid False Claims, per Federal Deficit Reduction Act of 2005, Section 6032 [MFC-1] (English, DOCX 18.46 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 DOC file, 36 KB,  Certification of Treatment of Emergency Medical Condition [MHL-EMT] (English, DOC 36 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, 73.98 KB,  Provider Enrollment Data Collection Form and Registration Instructions [POSC-DC-PE] (English, PDF 73.98 KB)
Open DOCX file, 27.4 KB,  Provider Enrollment Data Collection Form and Registration Instructions [POSC-DC-PE] (English, DOCX 27.4 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 PDF file, 148.24 KB,  Federally Required Disclosures Form for Individual Practitioners (PE-FRD-IN) (English, PDF 148.24 KB)
Open DOC file, 41 KB,  Federally Required Disclosures Form for Individual Practitioners (PE-FRD-IN) (English, DOC 41 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, 67.94 KB,  MassHealth Trading Partner Agreement (English, PDF 67.94 KB)
Open DOC file, 112.5 KB,  MassHealth Trading Partner Agreement (English, DOC 112.5 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)

Behavioral Health

Behavioral Health - Reporting Adverse Incidents 

Chronic Disease and Rehabilitation Hospital

Open PDF file, 308.07 KB,  Quality Performance Incentive Payment for Discharge Planning Form (English, PDF 308.07 KB)
Open DOCX file, 24.01 KB,  Quality Performance Incentive Payment for Discharge Planning Form (English, DOCX 24.01 KB)

Community Behavioral Health Center

Open PDF file, 88.15 KB,  Community Behavioral Health Center Annual Report Form (English, PDF 88.15 KB)
Open DOCX file, 14.27 KB,  Community Behavioral Health Center Annual Report Form (English, DOCX 14.27 KB)

Community Health Centers

Open PDF file, 73.91 KB,  Application for Community Health Centers Participating in 340B Drug-Pricing Program for MassHealth Members [PHM-340B-1] (English, PDF 73.91 KB)
Open TXT file, 2.84 KB,  Application for Community Health Centers Participating in 340B Drug-Pricing Program for MassHealth Members [PHM-340B-1] (English, TXT 2.84 KB)

Continuous Skilled Nursing

Open PDF file, 99.17 KB,  Retention Bonus Claim Attachment Form for Continuous Skilled Nursing (English, PDF 99.17 KB)
Open DOCX file, 27.8 KB,  Retention Bonus Claim Attachment Form for Continuous Skilled Nursing (English, DOCX 27.8 KB)

Day Habilitation

Open PDF file, 49.76 KB,  MassHealth Day Habilitation (DH) Provider Supplemental Payment Request Form (English, PDF 49.76 KB)
Open DOCX file, 26.09 KB,  MassHealth Day Habilitation (DH) Provider Supplemental Payment Request Form (English, DOCX 26.09 KB)

Durable Medical Equipment

Open PDF file, 193.54 KB,  Medical Necessity Review Form for Absorbent Products [MNR-AP] (English, PDF 193.54 KB)
Open DOCX file, 35.56 KB,  Medical Necessity Review Form for Absorbent Products [MNR-AP] (English, DOCX 35.56 KB)
Open PDF file, 156.19 KB,  Medical Necessity Review Form for Ambulatory Infusion (Insulin Pumps) (English, PDF 156.19 KB)
Open DOCX file, 32.2 KB,  Medical Necessity Review Form for Ambulatory Infusion (Insulin Pumps) (English, DOCX 32.2 KB)
Open PDF file, 173.4 KB,  Medical Necessity Review Form for Durable Medical Equipment and Medical Supplies General Prescription (English, PDF 173.4 KB)
Open DOCX file, 30.19 KB,  Medical Necessity Review Form for Durable Medical Equipment and Medical Supplies General Prescription (English, DOCX 30.19 KB)
Open PDF file, 182.71 KB,  Medical Necessity Review Form for Enteral Nutrition Products (English, PDF 182.71 KB)
Open DOCX file, 20.8 KB,  Medical Necessity Review Form for Enteral Nutrition Products (English, DOCX 20.8 KB)
Open PDF file, 166.84 KB,  Medical Necessity Review Form for Gait Trainers (English, PDF 166.84 KB)
Open DOCX file, 21.66 KB,  Medical Necessity Review Form for Gait Trainers (English, DOCX 21.66 KB)
Open PDF file, 209.84 KB,  Medical Necessity Review Form for Hospital Beds (English, PDF 209.84 KB)
Open DOCX file, 21.65 KB,  Medical Necessity Review Form for Hospital Beds (English, DOCX 21.65 KB)
Open PDF file, 152.52 KB,  Medical Necessity Review Form for Support Surfaces [MNR-SS] (English, PDF 152.52 KB)
Open DOC file, 33 KB,  Medical Necessity Review Form for Support Surfaces [MNR-SS] (English, DOC 33 KB)
Open PDF file, 269.09 KB,  Personal Emergency Response System (PERS) General Prescription Form [PERS-GPF] (English, PDF 269.09 KB)
Open DOC file, 107.74 KB,  Personal Emergency Response System (PERS) General Prescription Form [PERS-GPF] (English, DOC 107.74 KB)
Open PDF file, 55.92 KB,  Temporary Replacement Equipment Form (English, PDF 55.92 KB)
Open DOCX file, 19.82 KB,  Temporary Replacement Equipment Form (English, DOCX 19.82 KB)

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