MassHealth Provider Forms Used by Multiple Provider Types A-P

Billing Guidelines

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

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

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

Open PDF file, 94.67 KB,  FAQs on MassHealth Enrollment for Ordering, Referring, and Prescribing Providers (English, PDF 94.67 KB)

Open DOCX file, 24.81 KB,  FAQs on MassHealth Enrollment for Ordering, Referring, and Prescribing Providers (English, DOCX 24.81 KB)

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

Open PDF file, 708.77 KB,  Instructions for the Federally Required Disclosure Form for Entities (PE-FRD-E INSTRUCTIONS) (English, PDF 708.77 KB)

Open DOCX file, 758.13 KB,  Instructions for the Federally Required Disclosure Form for Entities (PE-FRD-E INSTRUCTIONS) (English, DOCX 758.13 KB)

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]

Open PDF file, 516.84 KB,  Instructions for the Federally Required Disclosure Form for Individuals (PE-FRD-IN INSTRUCTIONS) (English, PDF 516.84 KB)

Open DOCX file, 528.64 KB,  Instructions for the Federally Required Disclosure Form for Individuals (PE-FRD-IN INSTRUCTIONS) (English, DOCX 528.64 KB)

Open PDF file, 148.24 KB,  Federally Required Disclosures Form for Individual Practitioners (PE-FRD-IN) (English, PDF 148.24 KB)

Open DOC file, 41 KB,  Federally Required Disclosures Form for Individual Practitioners (PE-FRD-IN) (English, DOC 41 KB)

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 Personal Care Attendant PCP Summary Form

Open PDF file, 78.77 KB,  MassHealth Personal Care Attendant PCP Summary Form (English, PDF 78.77 KB)

Open DOCX file, 17.12 KB,  MassHealth Personal Care Attendant PCP Summary Form (English, DOCX 17.12 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)