offered by
MassHealth
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MassHealth Provider Forms

MassHealth Provider Forms Used by Multiple Provider Types

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Table of Contents

Billing Guidelines for MassHealth Physicians and Mid-level Providers [EPSDT-BG] (DOC 272.5 KB)
Billing Guidelines for MassHealth Physicians and Mid-level Providers [EPSDT-BG] (PDF 82.85 KB)
Certification for Payable Abortion [CPA-2] (RTF 233.23 KB)
Certification for Payable Abortion [CPA-2] (PDF 92.52 KB)
Criminal Offender Record Information (CORI) Request Form [CRF-1] (TXT 1.52 KB)
Criminal Offender Record Information (CORI) Request Form [CRF-1] (PDF 152.5 KB)
Federally Required Disclosures Form for Entities [PE-FRD-E] (PDF 198.93 KB)
Federally Required Disclosures Form for Entities [PE-FRD-E] (DOCX 27.52 KB)
Federally Required Disclosures Form for Individual Practitioners (PDF 148.43 KB)
Federally Required Disclosures Form for Individual Practitioners (DOC 35.5 KB)
HIV Resistance Testing [HIV-RTR] (TXT 1.48 KB)
HIV Resistance Testing [HIV-RTR] (PDF 559.53 KB)
Hysterectomy Information Form [HI-1] (RTF 467.86 KB)
Hysterectomy Information Form [HI-1] (PDF 50.68 KB)
MassHealth Community Services Critical Incident Report Form [CIRF] (TXT 14.8 KB)
MassHealth Community Services Critical Incident Report Form [CIRF] (PDF 204.5 KB)
MassHealth Provider Contract for Individuals (GEN-15) (PDF 45.73 KB)
MassHealth Provider Contract for Individuals (GEN-15) (DOC 39 KB)
PCC Enhanced Fee Codes as of 01/01/2011 (TXT 1.53 KB)
PCC Enhanced Fee Codes as of 01/01/2011 (PDF 19.42 KB)
PCC Plan Contract Fourth Amended and Restated (TXT 44.12 KB)
PCC Plan Contract Fourth Amended and Restated (PDF 64.3 KB)
PCC Plan Handbook (PDF 985.64 KB)
Preadmission Screening Form (Acute) [PAS-A] (PDF 161.9 KB)
Preadmission Screening Form (Chronic Rehab) [PAS-CR] (TXT 7.92 KB)
Preadmission Screening Form (Chronic Rehab) [PAS-CR] (PDF 270.63 KB)
Primary Care Clinician Referral Form [PCC-RF] (DOC 34.5 KB)
Primary Care Clinician Referral Form [PCC-RF] (PDF 47.56 KB)
Prior Authorization Request (PA-1) (DOC 34.5 KB)
Prior Authorization Request [PA-1] (PDF 77.5 KB)
Provider Contract for Entities [GEN-16] (PDF 55.43 KB)
Provider Contract for Entities [GEN-16] (DOC 47 KB)
Request and Justification for Therapy Services [THP-2] (DOC 34 KB)
Request and Justification for Therapy Services [THP-2] (PDF 85.53 KB)
Request for Services (DOCX 23.26 KB)
Request for Services (PDF 86.19 KB)
Sterilization Consent Form Ages 18-20 [CS-18] (RTF 68.65 KB)
Sterilization Consent Form Ages 18-20 [CS-18] (PDF 31.73 KB)
Sterilization Consent Form Ages 18-20 Spanish [CS-18S] (RTF 82.83 KB)
Sterilization Consent Form Ages 18-20 Spanish [CS-18S] (PDF 33.79 KB)
Sterilization Consent Form Ages 21 and Older [CS-21] (RTF 69.83 KB)
Sterilization Consent Form Ages 21 and Older [CS-21] (PDF 31.66 KB)
Sterilization Consent Form Ages 21 and Older Spanish [CS-21S] (RTF 84.1 KB)
Sterilization Consent Form Ages 21 and Older Spanish [CS-21S] (PDF 40.26 KB)
Vision Care Material Order Form [VIS-1] (PDF 100.39 KB)
Vision Care Material Order Form [VIS-1] (TXT 3.6 KB)
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