MassHealth Provider Forms Used by Multiple Provider Types

Billing Guidelines

Open DOC file, 272.5 KB, for Billing Guidelines for MassHealth Physicians and Mid-level Providers [EPSDT-BG] (DOC 272.5 KB)

Open PDF file, 82.85 KB, for Billing Guidelines for MassHealth Physicians and Mid-level Providers [EPSDT-BG] (PDF 82.85 KB)

Certification for Payable Abortion [CPA-2]

Open RTF file, 233.23 KB, for Certification for Payable Abortion [CPA-2] (RTF 233.23 KB)

Open PDF file, 92.52 KB, for Certification for Payable Abortion [CPA-2] (PDF 92.52 KB)

Criminal Offender Record Information (CORI) Request Form

Open DOCX file, 15.45 KB, for Criminal Offender Record Information (CORI) Request Form [CRF-1] (DOCX 15.45 KB)

Open PDF file, 152.5 KB, for Criminal Offender Record Information (CORI) Request Form [CRF-1] (PDF 152.5 KB)

Federally Required Disclosures Form for Entities [PE-FRD-E]

Open PDF file, 919.04 KB, for Instructions for the Federally Required Disclosure Form for Entities (PE-FRD-E INSTRUCTIONS) (PDF 919.04 KB)

Open DOCX file, 768.63 KB, for Instructions for the Federally Required Disclosure Form for Entities (PE-FRD-E INSTRUCTIONS) (DOCX 768.63 KB)

Open PDF file, 246.65 KB, for Federally Required Disclosures Form for Entities [PE-FRD-E] (PDF 246.65 KB)

Open DOCX file, 27.67 KB, for Federally Required Disclosures Form for Entities [PE-FRD-E] (DOCX 27.67 KB)

Federally Required Disclosures Form for Individual Practitioners [PE-FRD-IN]

Open PDF file, 805.28 KB, for Instructions for the Federally Required Disclosure Form for Individuals (PE-FRD-IN INSTRUCTIONS) (PDF 805.28 KB)

Open DOCX file, 725.91 KB, for Instructions for the Federally Required Disclosure Form for Individuals (PE-FRD-IN INSTRUCTIONS) (DOCX 725.91 KB)

Open PDF file, 148.43 KB, for Federally Required Disclosures Form for Individual Practitioners (PE-FRD-IN) (PDF 148.43 KB)

Open DOC file, 35.5 KB, for Federally Required Disclosures Form for Individual Practitioners (PE-FRD-IN) (DOC 35.5 KB)

HIV Resistance Testing [HIV-RTR]

Open PDF file, 559.53 KB, for HIV Resistance Testing [HIV-RTR] (PDF 559.53 KB)

Open TXT file, 1.48 KB, for HIV Resistance Testing [HIV-RTR] (TXT 1.48 KB)

Hysterectomy Information Form [HI-1]

Open PDF file, 50.68 KB, for Hysterectomy Information Form [HI-1] (PDF 50.68 KB)

Open RTF file, 467.86 KB, for Hysterectomy Information Form [HI-1] (RTF 467.86 KB)

MassHealth Community Services Critical Incident Report Form [CIRF]

Open TXT file, 14.8 KB, for MassHealth Community Services Critical Incident Report Form [CIRF] (TXT 14.8 KB)

Open PDF file, 204.5 KB, for MassHealth Community Services Critical Incident Report Form [CIRF] (PDF 204.5 KB)

MassHealth Provider Contract for Individuals (GEN-15)

Open PDF file, 45.73 KB, for MassHealth Provider Contract for Individuals (GEN-15) (PDF 45.73 KB)

Open DOC file, 39 KB, for MassHealth Provider Contract for Individuals (GEN-15) (DOC 39 KB)

PCC Enhanced Fee Codes as of 01/01/2011

Open TXT file, 1.53 KB, for PCC Enhanced Fee Codes as of 01/01/2011 (TXT 1.53 KB)

Open PDF file, 19.42 KB, for PCC Enhanced Fee Codes as of 01/01/2011 (PDF 19.42 KB)

PCC Plan Contract Fourth Amended and Restated

Open TXT file, 44.12 KB, for PCC Plan Contract Fourth Amended and Restated (TXT 44.12 KB)

Open PDF file, 64.3 KB, for PCC Plan Contract Fourth Amended and Restated (PDF 64.3 KB)

PCC Plan Handbook

Open PDF file, 985.64 KB, for PCC Plan Handbook (PDF 985.64 KB)

Preadmission Screening Form (Acute) [PAS-A]

Open PDF file, 161.9 KB, for Preadmission Screening Form (Acute) [PAS-A] (PDF 161.9 KB)

Preadmission Screening Form (Chronic Rehab) [PAS-CR]

Open TXT file, 7.92 KB, for Preadmission Screening Form (Chronic Rehab) [PAS-CR] (TXT 7.92 KB)

Open PDF file, 270.63 KB, for Preadmission Screening Form (Chronic Rehab) [PAS-CR] (PDF 270.63 KB)

Primary Care Clinician Referral Form [PCC-RF]

Open PDF file, 47.56 KB, for Primary Care Clinician Referral Form [PCC-RF] (PDF 47.56 KB)

Open DOC file, 34.5 KB, for Primary Care Clinician Referral Form [PCC-RF] (DOC 34.5 KB)

Prior Authorization Request [PA-1]

Open PDF file, 77.5 KB, for Prior Authorization Request [PA-1] (PDF 77.5 KB)

Open DOC file, 34.5 KB, for Prior Authorization Request (PA-1) (DOC 34.5 KB)

Provider Contract for Entities [GEN-16]

Open DOC file, 47 KB, for Provider Contract for Entities [GEN-16] (DOC 47 KB)

Open PDF file, 55.43 KB, for Provider Contract for Entities [GEN-16] (PDF 55.43 KB)

Request and Justification for Therapy Services [THP-2]

Open PDF file, 85.53 KB, for Request and Justification for Therapy Services [THP-2] (PDF 85.53 KB)

Open DOC file, 34 KB, for Request and Justification for Therapy Services [THP-2] (DOC 34 KB)

Request for Services

Open DOCX file, 23.26 KB, for Request for Services (DOCX 23.26 KB)

Open PDF file, 86.19 KB, for Request for Services (PDF 86.19 KB)

Sterilization Consent Form Ages 18-20 [CS-18]

Open PDF file, 31.73 KB, for Sterilization Consent Form Ages 18-20 [CS-18] (PDF 31.73 KB)

Open RTF file, 68.65 KB, for Sterilization Consent Form Ages 18-20 [CS-18] (RTF 68.65 KB)

Open PDF file, 33.79 KB, for Sterilization Consent Form Ages 18-20 Spanish [CS-18S] (PDF 33.79 KB)

Open RTF file, 82.83 KB, for Sterilization Consent Form Ages 18-20 Spanish [CS-18S] (RTF 82.83 KB)

Sterilization Consent Form Ages 21 and Older [CS-21]

Open RTF file, 69.83 KB, for Sterilization Consent Form Ages 21 and Older [CS-21] (RTF 69.83 KB)

Open PDF file, 31.66 KB, for Sterilization Consent Form Ages 21 and Older [CS-21] (PDF 31.66 KB)

Open RTF file, 84.1 KB, for Sterilization Consent Form Ages 21 and Older Spanish [CS-21S] (RTF 84.1 KB)

Open PDF file, 40.26 KB, for Sterilization Consent Form Ages 21 and Older Spanish [CS-21S] (PDF 40.26 KB)

Vision Care Material Order Form [VIS-1]

Open PDF file, 100.39 KB, for Vision Care Material Order Form [VIS-1] (PDF 100.39 KB)

Open TXT file, 3.6 KB, for Vision Care Material Order Form [VIS-1] (TXT 3.6 KB)