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MassHealth Provider Forms by Provider Type H - M

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HCBS Waiver

Open PDF file, 126.16 KB,  Direct Care Worker COVID-19 Vaccine Attestation Form—March 2022 (English, PDF 126.16 KB)
Open DOCX file, 29.38 KB,  Direct Care Worker COVID-19 Vaccine Attestation Form—March 2022 (English, DOCX 29.38 KB)
Open PDF file, 99.13 KB,  Formulario de declaración para vacunación contra COVID-19 para Asistentes de atención directa—Marzo de 2022 (English, PDF 99.13 KB)
Open DOCX file, 29.31 KB,  Formulario de declaración para vacunación contra COVID-19 para Asistentes de atención directa—Marzo de 2022 (English, DOCX 29.31 KB)
Open PDF file, 135.18 KB,  Non-Agency (Self-Employed) Provider COVID-19 Vaccine Attestation Form—March 2022 (English, PDF 135.18 KB)
Open DOCX file, 26.58 KB,  Non-Agency (Self-Employed) Provider COVID-19 Vaccine Attestation Form—March 2022 (English, DOCX 26.58 KB)
Open PDF file, 118.55 KB,  Formulario de declaración para vacunación contra COVID-19 para Proveedores sin agencias (empleados por cuenta propia)—Marzo de 2022 (English, PDF 118.55 KB)
Open DOCX file, 29.45 KB,  Formulario de declaración para vacunación contra COVID-19 para Proveedores sin agencias (empleados por cuenta propia)—Marzo de 2022 (English, DOCX 29.45 KB)

Home Health Agency

Open PDF file, 79.34 KB,  Homebound Assessment Form [HBA] (English, PDF 79.34 KB)
Open DOC file, 33.5 KB,  Homebound Assessment Form [HBA] (English, DOC 33.5 KB)
Open PDF file, 135.67 KB,  Home Health Coverage Determination Form [HHCD-1] (English, PDF 135.67 KB)
Open DOC file, 26 KB,  Home Health Coverage Determination Form [HHCD-1] (English, DOC 26 KB)
Open PDF file, 63.16 KB,  MassHealth Home Health Agency Member Transfer Form (English, PDF 63.16 KB)
Open DOCX file, 25.25 KB,  MassHealth Home Health Agency Member Transfer Form (English, DOCX 25.25 KB)
Open PDF file, 157.08 KB,  Member Connection Form [MCF] (English, PDF 157.08 KB)
Open DOCX file, 31.63 KB,  Member Connection Form [MCF] (English, DOCX 31.63 KB)
Open PDF file, 626.37 KB,  Request and Justification for Home Health Therapy Services [HHA-2] (English, PDF 626.37 KB)
Open DOC file, 33.5 KB,  Request and Justification for Home Health Therapy Services [HHA-2] (English, DOC 33.5 KB)
Open PDF file, 566.26 KB,  Request and Justification for Skilled Nursing Visits and Home Health Aide Services [PA-HHA-SN] (English, PDF 566.26 KB)
Open DOC file, 32.5 KB,  Request and Justification for Skilled Nursing Visits and Home Health Aide Services [PA-HHA-SN] (English, DOC 32.5 KB)

Hospice

Open PDF file, 124.07 KB,  MassHealth Hospice Election Form [HOS-1] (English, PDF 124.07 KB)
Open DOCX file, 49.46 KB,  MassHealth Hospice Election Form [HOS-1] (English, DOCX 49.46 KB)

Hospitals

Open PDF file, 343.68 KB,  Guide to Identifying ConnectorCare Coverage (English, PDF 343.68 KB)
Open DOCX file, 382.14 KB,  Guide to Identifying ConnectorCare Coverage (English, DOCX 382.14 KB)
Open PDF file, 115.02 KB,  Notification of Birth Form (NOB-1) (English, PDF 115.02 KB)
Open DOCX file, 73.05 KB,  Notification of Birth Form (NOB-1) (English, DOCX 73.05 KB)
Open PDF file, 74.88 KB,  Preadmission Screening Waiver Request for Acute Inpatient Hospitals (English, PDF 74.88 KB)
Open DOC file, 41 KB,  Preadmission Screening Waiver Request for Acute Inpatient Hospitals (English, DOC 41 KB)

Independent Nurse

Open PDF file, 134.23 KB,  Independent Nurse COVID-19 Vaccine Attestation Form—March 2022 (English, PDF 134.23 KB)
Open DOCX file, 28.48 KB,  Independent Nurse COVID-19 Vaccine Attestation Form—March 2022 (English, DOCX 28.48 KB)
Open PDF file, 117.88 KB,  Formulario de declaración para vacunación contra COVID-19 para Profesionales de Enfermería Independientes—Marzo de 2022 (English, PDF 117.88 KB)
Open DOCX file, 29.18 KB,  Formulario de declaración para vacunación contra COVID-19 para Profesionales de Enfermería Independientes—Marzo de 2022 (English, DOCX 29.18 KB)
Open PDF file, 50.75 KB,  Request and Justification for Continuous Skilled Nursing Services [PA-PDN-1] (English, PDF 50.75 KB)
Open RTF file, 767.05 KB,  Request and Justification for Continuous Skilled Nursing Services [PA-PDN-1] (English, RTF 767.05 KB)

Indian Health Services

Open PDF file, 60.28 KB,  Provider Contract for Indian Health Services (GEN-17) (English, PDF 60.28 KB)
Open DOC file, 40.5 KB,  Provider Contract for Indian Health Services (GEN-17) (English, DOC 40.5 KB)

Long Term Care

Open PDF file, 147.81 KB,  A Guide to the Program of All-inclusive Care (PACE) for Elderly MassHealth Members (English, PDF 147.81 KB)
Open DOC file, 183.5 KB,  A Guide to the Program of All-inclusive Care (PACE) for Elderly MassHealth Members (English, DOC 183.5 KB)
Open PDF file, 146.22 KB,  PNA Reporting Form for Deceased MH Members (English, PDF 146.22 KB)
Open TXT file, 930 BYTES,  PNA Reporting Form for Deceased MH Members (English, TXT 930 BYTES)
Open PDF file, 85.41 KB,  Status Change for Members in a Nursing Facility or Chronic Disease and Rehabilitation Inpatient Hospital [SC-1] (English, PDF 85.41 KB)
Open DOCX file, 22.51 KB,  Status Change for Members in a Nursing Facility or Chronic Disease and Rehabilitation Inpatient Hospital [SC-1] (English, DOCX 22.51 KB)

Long Term Care - Community

Open PDF file, 144.68 KB,  Minimum Data Set - Home Care MDS-HC Version 2.0 (English, PDF 144.68 KB)
Open TXT file, 33.99 KB,  Minimum Data Set - Home Care MDS-HC Version 2.0 (English, TXT 33.99 KB)
Open PDF file, 62.84 KB,  Notice of Clinical Eligibility Determination for State-funded Community-Based Long-Term Services and Supports (English, PDF 62.84 KB)
Open DOCX file, 40.38 KB,  Notice of Clinical Eligibility Determination for State-funded Community-Based Long-Term Services and Supports (English, DOCX 40.38 KB)
Open PDF file, 62.63 KB,  Aviso de Determinación de elegibilidad clínica para recibir Servicios y Apoyos a Largo Plazo en la comunidad con subsidios del estado (English, PDF 62.63 KB)
Open DOCX file, 39.77 KB,  Aviso de Determinación de elegibilidad clínica para recibir Servicios y Apoyos a Largo Plazo en la comunidad con subsidios del estado (English, DOCX 39.77 KB)
Open PDF file, 64.43 KB,  Physician Summary Form [PSF-1] (English, PDF 64.43 KB)
Open TXT file, 2.03 KB,  Physician Summary Form [PSF-1] (English, TXT 2.03 KB)

Long Term Care - Nursing Facility

Open PDF file, 119.56 KB,  Electronic Management Minutes Questionnaire (MMQ) Certification Statement (English, PDF 119.56 KB)
Open DOC file, 39.5 KB,  Electronic Management Minutes Questionnaire (MMQ) Certification Statement (English, DOC 39.5 KB)
Open PDF file, 19.17 KB,  Notice of Nursing Facility Residents' Rights [LTC-013] (English, PDF 19.17 KB)
Open RTF file, 29.86 KB,  Notice of Nursing Facility Residents' Rights [LTC-013] (English, RTF 29.86 KB)
Open PDF file, 103.35 KB,  Nursing-Facility Services Clinical Eligibility [NF-AIH-ADM-O (Rev. 09/09)] (English, PDF 103.35 KB)
Open TXT file, 9.05 KB,  Nursing-Facility Services Clinical Eligibility [NF-AIH-ADM-O (Rev. 09/09)] (English, TXT 9.05 KB)
Open PDF file, 95.48 KB,  Nursing Facility Census Data Collection Form [NF-CDCF] (English, PDF 95.48 KB)
Open TXT file, 1.17 KB,  Nursing Facility Census Data Collection Form [NF-CDCF] (English, TXT 1.17 KB)
Open PDF file, 68.38 KB,  Nursing Facility Contract [CON-NF] (English, PDF 68.38 KB)
Open DOCX file, 26.73 KB,  Nursing Facility Contract [CON-NF] (English, DOCX 26.73 KB)
Open PDF file, 459.67 KB,  RY2018 Nursing Facility Direct Care Program Compliance Form Instructions [NF-DCACF-1] (English, PDF 459.67 KB)
Open DOC file, 82 KB,  RY2018 Nursing Facility Direct Care Program Compliance Form Instructions [NF-DCACF-1] (English, DOC 82 KB)
Open XLSX file, 31.46 KB,  RY2018 Nursing Facility Direct Care Program Compliance Manual Form (English, XLSX 31.46 KB)
Open XLSX file, 13.18 KB,  RY2018 Nursing Facility Direct Care Program Contract Registration Form (English, XLSX 13.18 KB)
Open PDF file, 813.2 KB,  RY2018 Nursing Facility Direct Care Program FAQs (English, PDF 813.2 KB)
Open DOC file, 224.5 KB,  RY2018 Nursing Facility Direct Care Program FAQs (English, DOC 224.5 KB)

Mental Health Center

Open PDF file, 88.18 KB,  Mental Health Center Annual Report Form [MHC-ARF] (English, PDF 88.18 KB)
Open DOCX file, 15.71 KB,  Mental Health Center Annual Report Form [MHC-ARF] (English, DOCX 15.71 KB)
Open XLSX file, 13.77 KB,  Facility Staffing Pattern (English, XLSX 13.77 KB)

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