Cost Estimate Form

Asthma Control Tests for Children and Adults

Massachusetts Adult Asthma Action Plans
English
Spanish
Portuguese
Russian

Massachusetts Child Asthma Action Plan

Notification Form – Here to There Program
(Certain commercial groups only)

Primary Care Clinician (PCC) Plan Community Support Program Referral Form

Provider Information Change Form

Advanced Care Planning Toolkit & Forms

Behavioral Health Level of Care Request Form
(for initial requests – MA providers only)

Substance Use Disorder Treatment Addendum Form
(must be attached for any request for treatment of SUD)

Applied Behavioral Analysis for Autism Request Form (for non-MA providers)

Applied Behavioral Analysis for Autism Request Form (for non-MA providers) NEW

Applied Behavioral Analysis for Autism Request Form (for Early Intervention providers) NEW

Applied Behavioral Analysis Extended Service Request Form

Applied Behavioral Analysis Extended Service Request Form NEW

Applied Behavioral Analysis Extended Service Request Form (for Early Intervention providers) NEW

Behavioral Health Referral to Out of Network Provider

Combined MCE Behavioral Health Provider/Primary Care Provider Communication
(Be Healthy Only)

Dialectical Behavior Therapy Initial Review (for non-MA providers)

Dialectical Behavior Therapy Extended Review (for non-MA providers)

Family Stabilization Team Concurrent Review Form (for non-MA providers)

Family Stabilization Team Discharge Form (for non-MA providers)

Family Stabilization Team Initial Request Form (for non-MA providers)

Functional Behavior Assessment for Autism Spectrum Disorder Request Form

Inpatient Mental Health Clinical Review Form (for non-MA providers)

Inpatient Substance Use Disorder Clinical Review Form (for non-MA providers)

MassHealth Daily Adverse Incident Report (Be Healthy Only)

Member Authorization for Behavior Health Provider and Behavior Health Provider Communication

Member Authorization for PCP and Behavior Health Provider Communication

Mental Health Intermediate Care Request Form
(for providers outside of MA and all additional care requests)

Neuropsychological and Psychological Testing
Prior Authorization Request - NEW!

Outpatient MH/SA Treatment Request (for non-MA providers)

Repetitive Transcranial Magnetic Stimulation (RTMS)
Prior Authorization Request - NEW!

Substance Use Disorder Intermediate Care Request Form (for non-MA providers)

Combined MCE Behavioral Health Provider/Primary Care Provider Communication
(HNE Be Healthy Only)

EFT/ERA Request
Submit Electronically
Print and send pdf
EFT/ERA Request - Instructions
ERA/EFT FAQs
835 ERA/EFT Companion Guide

Request for Claim Review Form

Request for Claim Review Guide

Medicare Appeal Waiver of Liability Statement Form