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MassHealth Provider Forms Used by Multiple Provider Types
Table of Contents
Billing Guidelines
Certification for Payable Abortion [CPA-2]
Open PDF file, 192.51 KB,
Certification for Payable Abortion [CPA-2]
(English, PDF 192.51 KB)
Open DOCX file, 69.09 KB,
Certification for Payable Abortion [CPA-2]
(English, DOCX 69.09 KB)
Criminal Offender Record Information (CORI) Request Form
Open PDF file, 152.5 KB,
Criminal Offender Record Information (CORI) Request Form [CRF-1]
(English, PDF 152.5 KB)
Open DOCX file, 15.45 KB,
Criminal Offender Record Information (CORI) Request Form [CRF-1]
(English, DOCX 15.45 KB)
FAQs on MassHealth Enrollment for Ordering, Referring, and Prescribing Providers
Federally Required Disclosures Form for Entities [PE-FRD-E]
Open PDF file, 185.21 KB,
Federally Required Disclosures Form for Entities [PE-FRD-E]
(English, PDF 185.21 KB)
Open DOCX file, 27.77 KB,
Federally Required Disclosures Form for Entities [PE-FRD-E]
(English, DOCX 27.77 KB)
Federally Required Disclosures Form for Individual Practitioners [PE-FRD-IN]
HIV Resistance Testing [HIV-RTR]
Open PDF file, 559.53 KB,
HIV Resistance Testing [HIV-RTR]
(English, PDF 559.53 KB)
Open TXT file, 1.48 KB,
HIV Resistance Testing [HIV-RTR]
(English, TXT 1.48 KB)
Hysterectomy Information Form [HI-1]
Open PDF file, 50.68 KB,
Hysterectomy Information Form [HI-1]
(English, PDF 50.68 KB)
Open RTF file, 467.86 KB,
Hysterectomy Information Form [HI-1]
(English, RTF 467.86 KB)
MassHealth Community Services Critical Incident Report Form [CIRF]
Open PDF file, 166.83 KB,
MassHealth Community Services Critical Incident Report Form [CIRF]
(English, PDF 166.83 KB)
Open DOCX file, 103.71 KB,
MassHealth Community Services Critical Incident Report Form [CIRF]
(English, DOCX 103.71 KB)
MassHealth Provider Contract for Individuals (GEN-15)
Open PDF file, 49.75 KB,
MassHealth Provider Contract for Individuals (GEN-15)
(English, PDF 49.75 KB)
Open DOC file, 31.5 KB,
MassHealth Provider Contract for Individuals (GEN-15)
(English, DOC 31.5 KB)
MassHealth Special Program Provider Contract (GEN-19)
Open PDF file, 58.24 KB,
MassHealth Special Program Provider Contract (GEN-19)
(English, PDF 58.24 KB)
Open DOC file, 32.5 KB,
MassHealth Special Program Provider Contract (GEN-19)
(English, DOC 32.5 KB)
PCC Enhanced Fee Codes as of 01/01/2011
Open PDF file, 19.42 KB,
PCC Enhanced Fee Codes as of 01/01/2011
(English, PDF 19.42 KB)
Open TXT file, 1.53 KB,
PCC Enhanced Fee Codes as of 01/01/2011
(English, TXT 1.53 KB)
PCC Plan Contract Fourth Amended and Restated
Open PDF file, 64.3 KB,
PCC Plan Contract Fourth Amended and Restated
(English, PDF 64.3 KB)
Open TXT file, 44.12 KB,
PCC Plan Contract Fourth Amended and Restated
(English, TXT 44.12 KB)
PCC Provider Handbook
Open PDF file, 468.55 KB,
PCC Provider Handbook
(English, PDF 468.55 KB)
Open DOCX file, 601.45 KB,
PCC Provider Handbook
(English, DOCX 601.45 KB)
Preadmission Screening Form (Acute) [PAS-A]
Open PDF file, 161.9 KB,
Preadmission Screening Form (Acute) [PAS-A]
(English, PDF 161.9 KB)
Preadmission Screening Form (Chronic Rehab) [PAS-CR]
Open PDF file, 270.63 KB,
Preadmission Screening Form (Chronic Rehab) [PAS-CR]
(English, PDF 270.63 KB)
Open TXT file, 7.92 KB,
Preadmission Screening Form (Chronic Rehab) [PAS-CR]
(English, TXT 7.92 KB)
Primary Care Clinician Referral Form [PCC-RF]
Open PDF file, 47.56 KB,
Primary Care Clinician Referral Form [PCC-RF]
(English, PDF 47.56 KB)
Open DOC file, 34.5 KB,
Primary Care Clinician Referral Form [PCC-RF]
(English, DOC 34.5 KB)
Prior Authorization Request [PA-1]
Open PDF file, 94.29 KB,
Prior Authorization Request [PA-1]
(English, PDF 94.29 KB)
Open DOCX file, 17.77 KB,
Prior Authorization Request [PA-1]
(English, DOCX 17.77 KB)
Provider Contract for Entities [GEN-16]
Open PDF file, 63.08 KB,
MassHealth Provider Contract for Entities [GEN-16]
(English, PDF 63.08 KB)
Open DOC file, 38.5 KB,
MassHealth Provider Contract for Entities [GEN-16]
(English, DOC 38.5 KB)
Request and Justification for Therapy Services [THP-2]
Open PDF file, 85.53 KB,
Request and Justification for Therapy Services [THP-2]
(English, PDF 85.53 KB)
Open DOC file, 34 KB,
Request and Justification for Therapy Services [THP-2]
(English, DOC 34 KB)
Request for Services
Open PDF file, 86.19 KB,
Request for Services
(English, PDF 86.19 KB)
Open DOCX file, 23.26 KB,
Request for Services
(English, DOCX 23.26 KB)
Rest Home Provider Contract
Open PDF file, 64.02 KB,
Rest Home Provider Contract [CON-RH]
(English, PDF 64.02 KB)
Open DOCX file, 26.58 KB,
Rest Home Provider Contract [CON-RH]
(English, DOCX 26.58 KB)
Sterilization Consent Form Ages 18-20 [CS-18]
Open PDF file, 31.73 KB,
Sterilization Consent Form Ages 18-20 [CS-18]
(English, PDF 31.73 KB)
Open RTF file, 68.65 KB,
Sterilization Consent Form Ages 18-20 [CS-18]
(English, RTF 68.65 KB)
Open PDF file, 33.79 KB,
Sterilization Consent Form Ages 18-20 Spanish [CS-18S]
(English, PDF 33.79 KB)
Open RTF file, 82.83 KB,
Sterilization Consent Form Ages 18-20 Spanish [CS-18S]
(English, RTF 82.83 KB)
Sterilization Consent Form Ages 21 and Older [CS-21]
Open PDF file, 31.66 KB,
Sterilization Consent Form Ages 21 and Older [CS-21]
(English, PDF 31.66 KB)
Open RTF file, 69.83 KB,
Sterilization Consent Form Ages 21 and Older [CS-21]
(English, RTF 69.83 KB)
Open PDF file, 40.26 KB,
Sterilization Consent Form Ages 21 and Older Spanish [CS-21S]
(English, PDF 40.26 KB)
Open RTF file, 84.1 KB,
Sterilization Consent Form Ages 21 and Older Spanish [CS-21S]
(English, RTF 84.1 KB)
Sterilization Consent Form Guidelines
Open PDF file, 545.99 KB,
Sterilization Consent Form Guidelines
(English, PDF 545.99 KB)
Open DOCX file, 180.55 KB,
Sterilization Consent Form Guidelines
(English, DOCX 180.55 KB)
Vision Care Material Order Form [VIS-1]
Open PDF file, 100.39 KB,
Vision Care Material Order Form [VIS-1]
(English, PDF 100.39 KB)
Open TXT file, 3.6 KB,
Vision Care Material Order Form [VIS-1]
(English, TXT 3.6 KB)
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