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MassHealth Provider Forms by Provider Type O - T

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Orthotics

Open PDF file, 171.3 KB,  MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Foot Orthoses, Footwear, and Modifications [ORT-ND] (English, PDF 171.3 KB)
Open DOC file, 35 KB,  MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Foot Orthoses, Footwear, and Modifications [ORT-ND] (English, DOC 35 KB)
Open PDF file, 230.47 KB,  MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Therapeutic Shoes, Inserts, and Modifications [ORT-D] (English, PDF 230.47 KB)
Open DOC file, 36.5 KB,  MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Therapeutic Shoes, Inserts, and Modifications [ORT-D] (English, DOC 36.5 KB)

Outpatient Hospitals

Open PDF file, 56.17 KB,  Application for Outpatient Departments Participating in 340B Drug-Pricing Program for MassHealth Members [PHM-340B-2] (English, PDF 56.17 KB)
Open TXT file, 2.66 KB,  Application for Outpatient Departments Participating in 340B Drug-Pricing Program for MassHealth Members [PHM-340B-2] (English, TXT 2.66 KB)

Personal Care

Open PDF file, 90.55 KB,  Consumer Agreement for PCA Fiscal Intermediary Services [PCA-3] (English, PDF 90.55 KB)
Open TXT file, 12.75 KB,  Consumer Agreement for PCA Fiscal Intermediary Services [PCA-3] (English, TXT 12.75 KB)
Open PDF file, 1.44 MB,  Consumer Assessment to Manage PCA Services [PCA-CA-1] (English, PDF 1.44 MB)
Open DOCX file, 32.9 KB,  Consumer Assessment to Manage PCA Services [PCA-CA-1] (English, DOCX 32.9 KB)
Open PDF file, 369.39 KB,  MassHealth Application for PCA Services [PCA-1] (English, PDF 369.39 KB)
Open TXT file, 19.5 KB,  MassHealth Application for PCA Services [PCA-1] (English, TXT 19.5 KB)
Open PDF file, 313.4 KB,  MassHealth Evaluation for Personal Care Attendant (PCA) Services [PCA-2] (English, PDF 313.4 KB)
Open TXT file, 7.65 KB,  MassHealth Evaluation for Personal Care Attendant (PCA) Services [PCA-2] (English, TXT 7.65 KB)
Open PDF file, 189.59 KB,  PCA Prior Authorization Adjustment Form [PCA-PAAF-1] (English, PDF 189.59 KB)
Open TXT file, 3.08 KB,  PCA Prior Authorization Adjustment Form [PCA-PAAF-1] (English, TXT 3.08 KB)
Open PDF file, 193.88 KB,  Personal Care Attendant Overtime Request Form [PCA-OAF] (English, PDF 193.88 KB)
Open DOC file, 54.5 KB,  Personal Care Attendant Overtime Request Form [PCA-OAF] (English, DOC 54.5 KB)
Open PDF file, 83.91 KB,  Personal Care Attendant Overtime Request Form [PCA-OAF] (Spanish) (English, PDF 83.91 KB)
Open DOC file, 57 KB,  Personal Care Attendant Overtime Request Form [PCA-OAF] (Spanish) (English, DOC 57 KB)
Open PDF file, 1.2 MB,  Personal Care Attendant PCA Service Agreement [PCA-SA-1] (English, PDF 1.2 MB)
Open DOCX file, 38.49 KB,  Personal Care Attendant PCA Service Agreement [PCA-SA-1] (English, DOCX 38.49 KB)
Open PDF file, 1.54 MB,  Personal Care Attendant PCA Service Agreement [PCA-SA-1] (Spanish) (English, PDF 1.54 MB)
Open DOCX file, 43.12 KB,  Personal Care Attendant PCA Service Agreement [PCA-SA-1] (Spanish) (English, DOCX 43.12 KB)
Open PDF file, 174.58 KB,  Personal Care Attendant Reevaluation Form [PCA-R] (English, PDF 174.58 KB)
Open TXT file, 6.55 KB,  Personal Care Attendant Reevaluation Form [PCA-R] (English, TXT 6.55 KB)
Open PDF file, 105.98 KB,  Personal Care Attendant Signature Form (English and Spanish) [PCA-S] (English, PDF 105.98 KB)
Open TXT file, 10.33 KB,  Personal Care Attendant Signature Form (English and Spanish) [PCA-S] (English, TXT 10.33 KB)
Open PDF file, 1.69 MB,  Personal Care Attendant (PCA) Surrogate/AP Assessment [PCA-AP-1] (English, PDF 1.69 MB)
Open DOCX file, 34.08 KB,  Personal Care Attendant (PCA) Surrogate/AP Assessment [PCA-AP-1] (English, DOCX 34.08 KB)
Open PDF file, 118.4 KB,  Review of Consumer Assessment to Manage PCA Services [PCA-RCA-1] (English, PDF 118.4 KB)
Open TXT file, 2.38 KB,  Review of Consumer Assessment to Manage PCA Services [PCA-RCA-1] (English, TXT 2.38 KB)
Open PDF file, 107.27 KB,  Standard Documentation to Include with a Prior Authorization Request for Personal Care Attendant (PCA) Services [PCA-SD] (English, PDF 107.27 KB)
Open TXT file, 11.48 KB,  Standard Documentation to Include with a Prior Authorization Request for Personal Care Attendant (PCA) Services [PCA-SD] (English, TXT 11.48 KB)

Pharmacy

Prior Authorization Forms for Pharmacy Services 

QMB-Only Providers

Open PDF file, 58.24 KB,  MassHealth Contract for QMB-Only Providers [QMB-1] (English, PDF 58.24 KB)
Open DOCX file, 23.64 KB,  MassHealth Contract for QMB-Only Providers [QMB-1] (English, DOCX 23.64 KB)

Rest Home

Open PDF file, 71.71 KB,  Status Change for Residents in a Rest Home [SC-1-RH] Form (English, PDF 71.71 KB)
Open TXT file, 1.93 KB,  Status Change for Residents in a Rest Home [SC-1-RH] Form (English, TXT 1.93 KB)

Substance Use Disorder

Open PDF file, 88.62 KB,  Substance Use Disorder Treatment Program Annual Report Form (English, PDF 88.62 KB)
Open DOCX file, 14.17 KB,  Substance Use Disorder Treatment Program Annual Report Form (English, DOCX 14.17 KB)

Transportation

Open PDF file, 69.24 KB,  MassHealth Medical Necessity Form for Nonemergency Ambulance/Wheelchair Van Transportation [MNR-NAT] (English, PDF 69.24 KB)
Open DOC file, 32.5 KB,  MassHealth Medical Necessity Form for Nonemergency Ambulance/Wheelchair Van Transportation [MNR-NAT] (English, DOC 32.5 KB)

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