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MassHealth Provider Forms Used by Multiple Provider Types

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Billing Guidelines

Billing Guidelines for MassHealth Physicians and Mid-level Providers [EPSDT-BG] (PDF 82.85 KB)
Billing Guidelines for MassHealth Physicians and Mid-level Providers [EPSDT-BG] (DOC 272.5 KB)

Certification for Payable Abortion [CPA-2]

Certification for Payable Abortion [CPA-2] (PDF 92.52 KB)
Certification for Payable Abortion [CPA-2] (RTF 233.23 KB)

Criminal Offender Record Information (CORI) Request Form

Criminal Offender Record Information (CORI) Request Form [CRF-1] (PDF 152.5 KB)
Criminal Offender Record Information (CORI) Request Form [CRF-1] (DOCX 15.45 KB)

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

Instructions for the Federally Required Disclosure Form for Entities (PE-FRD-E INSTRUCTIONS) (PDF 919.04 KB)
Instructions for the Federally Required Disclosure Form for Entities (PE-FRD-E INSTRUCTIONS) (DOCX 768.63 KB)
Federally Required Disclosures Form for Entities [PE-FRD-E] (PDF 246.65 KB)
Federally Required Disclosures Form for Entities [PE-FRD-E] (DOCX 27.67 KB)

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

Instructions for the Federally Required Disclosure Form for Individuals (PE-FRD-IN INSTRUCTIONS) (PDF 805.28 KB)
Instructions for the Federally Required Disclosure Form for Individuals (PE-FRD-IN INSTRUCTIONS) (DOCX 725.91 KB)
Federally Required Disclosures Form for Individual Practitioners (PE-FRD-IN) (PDF 148.43 KB)
Federally Required Disclosures Form for Individual Practitioners (PE-FRD-IN) (DOC 35.5 KB)

HIV Resistance Testing [HIV-RTR]

HIV Resistance Testing [HIV-RTR] (PDF 559.53 KB)
HIV Resistance Testing [HIV-RTR] (TXT 1.48 KB)

Hysterectomy Information Form [HI-1]

Hysterectomy Information Form [HI-1] (PDF 50.68 KB)
Hysterectomy Information Form [HI-1] (RTF 467.86 KB)

MassHealth Community Services Critical Incident Report Form [CIRF]

MassHealth Community Services Critical Incident Report Form [CIRF] (PDF 204.5 KB)
MassHealth Community Services Critical Incident Report Form [CIRF] (TXT 14.8 KB)

MassHealth Provider Contract for Individuals (GEN-15)

MassHealth Provider Contract for Individuals (GEN-15) (PDF 45.73 KB)
MassHealth Provider Contract for Individuals (GEN-15) (DOC 39 KB)

MassHealth Special Program Provider Contract (GEN-19)

MassHealth Special Program Provider Contract (GEN-19) (PDF 49.61 KB)
MassHealth Special Program Provider Contract (GEN-19) (DOCX 31.16 KB)

PCC Enhanced Fee Codes as of 01/01/2011

PCC Enhanced Fee Codes as of 01/01/2011 (PDF 19.42 KB)
PCC Enhanced Fee Codes as of 01/01/2011 (TXT 1.53 KB)

PCC Plan Contract Fourth Amended and Restated

PCC Plan Contract Fourth Amended and Restated (PDF 64.3 KB)
PCC Plan Contract Fourth Amended and Restated (TXT 44.12 KB)

PCC Plan Handbook

PCC Plan Handbook (PDF 985.64 KB)

Preadmission Screening Form (Acute) [PAS-A]

Preadmission Screening Form (Acute) [PAS-A] (PDF 161.9 KB)

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

Preadmission Screening Form (Chronic Rehab) [PAS-CR] (PDF 270.63 KB)
Preadmission Screening Form (Chronic Rehab) [PAS-CR] (TXT 7.92 KB)

Primary Care Clinician Referral Form [PCC-RF]

Primary Care Clinician Referral Form [PCC-RF] (PDF 47.56 KB)
Primary Care Clinician Referral Form [PCC-RF] (DOC 34.5 KB)

Prior Authorization Request [PA-1]

Prior Authorization Request [PA-1] (PDF 77.5 KB)
Prior Authorization Request (PA-1) (DOC 34.5 KB)

Provider Contract for Entities [GEN-16]

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]

Request and Justification for Therapy Services [THP-2] (PDF 85.53 KB)
Request and Justification for Therapy Services [THP-2] (DOC 34 KB)

Request for Services

Request for Services (PDF 86.19 KB)
Request for Services (DOCX 23.26 KB)

Rest Home Provider Contract

Rest Home Provider Contract (PDF 275.13 KB)
Rest Home Provider Contract (DOCX 40.08 KB)

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

Sterilization Consent Form Ages 18-20 [CS-18] (PDF 31.73 KB)
Sterilization Consent Form Ages 18-20 [CS-18] (RTF 68.65 KB)
Sterilization Consent Form Ages 18-20 Spanish [CS-18S] (PDF 33.79 KB)
Sterilization Consent Form Ages 18-20 Spanish [CS-18S] (RTF 82.83 KB)

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

Sterilization Consent Form Ages 21 and Older [CS-21] (PDF 31.66 KB)
Sterilization Consent Form Ages 21 and Older [CS-21] (RTF 69.83 KB)
Sterilization Consent Form Ages 21 and Older Spanish [CS-21S] (PDF 40.26 KB)
Sterilization Consent Form Ages 21 and Older Spanish [CS-21S] (RTF 84.1 KB)

Sterilization Consent Form Guidelines

Sterilization Consent Form Guidelines (PDF 545.99 KB)
Sterilization Consent Form Guidelines (DOCX 180.55 KB)

Vision Care Material Order Form [VIS-1]

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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