Health New England Forms | Where you matter

Forms

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Members

Advanced Care Planning Toolkit & Forms
Authorization of Personal Representative Form
Authorization of Personal Representative Form (Spanish)
Revocation of Authorization to Release PHI Form
Coordination of Benefits Questionnaire
Massage Reimbursement Form
Massage Reimbursement Form (Spanish)
Member Complaint/Appeal Request Form
Enrollment/Add/Termination Form Enrollment/Add/Termination Form (Spanish)
Health New England Wellness Reimbursement Form The Wellness Reimbursement Form (English and Spanish versions) is only available through online submission on our member portal. Log into your account or register now to start your submission.
Health Care Proxy Form Formulario Del Poder Para Tomar Decisiones Médicas Del Estado De Massachusetts
(FOR BAYSTATE HEALTH EMPLOYEES ONLY) Baystate Health Massage Reimbursement Form
Member Reimbursement Claim Form
Prior Approval Request Form (MEDICAL ONLY) Prior Authorization Addendum - Required for Out of Area Requests (this addendum MUST include the original Prior Approval Request Form (MEDICAL ONLY), see link above) Prior Authorization Request Guide
Reproductive Care Attestation Form (Instructions for Attestation Regarding a Requested Use or Disclosure of Protected Health Information Potentially Related to Reproductive Health Care) Reproductive Health Travel & Lodging Reimbursement Form
Tobacco Cessation Form
Tobacco Cessation Form (Spanish)

Providers

Most Used

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

Advanced Care Planning Toolkit & Forms

Behavioral Health Services

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 Early Intervention providers) NEW
Applied Behavioral Analysis Extended Service Request Form
Applied Behavior Analysis for Autism 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 (BeHealthy Partnership 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 Substance Use Disorder Clinical Review Form (for non-MA providers)
Inpatient Mental Health Clinical Review Form (for non-MA providers)
Massachusetts Standard Form for Applied Behavior Analysis Services Prior Authorization Requests
MassHealth Daily Adverse Incident Report (BeHealthy Partnership 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)

Children's Behavioral Health Initiative

Combined MCE Behavioral Health Provider/Primary Care Provider Communication (BeHealthy Partnership Only)

Claims/Appeals

EFT/ERA Request 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
Statement of Understanding

Clinical Request Forms

Absorbency Product Form (BeHealthy Partnership Only)
Cardiac Imaging Prior Authorization *All authorization requests for High Cost Radiology & Imaging are administered through eviCore healthcare. Please fax the completed request to eviCore, fax # (888) 693-3210.
Care Management Referral Form
Combined MCE Behavioral Health Provider/Primary Care Provider Communication (BeHealthy Partnership Only)
DME and Medical Supplies (BeHealthy Partnership Only)
Home Infusion (HI) Initial Prior Approval Request
Infertility Treatment Prior Approval Request
Medical Necessity Review Form For Enteral Nutrition Products (BeHealthy Partnership Only)
Notice of Medicare Non-Coverage
Obstetrical Pre-Registration
Orthotics and Prosthetics - Diabetic (BeHealthy Partnership Only)
Orthotics and Prosthetics - Non-Diabetic (BeHealthy Partnership Only)
PET CT Prior Authorization *All authorization requests for High Cost Radiology & Imaging are administered through eviCore healthcare. Please fax the completed request to eviCore, fax # (888) 693-3210.
Prior Approval Request Form (MEDICAL ONLY) Prior Authorization Addendum - Required for Out of Area Requests (this addendum MUST include the original Prior Approval Request Form (MEDICAL ONLY), see link above) Prior Authorization Request Guide
SNF/Rehab Clinical Review Form
Substance Use Disorder Treatment Addendum Form
Universal Health Plan/Home Health Authorization

Pharmacy

Review process for requests to bypass Step Therapy, Quantity Limit and Brand restrictions. Our providers may initiate the review request by completing our Medication Request Form (accessible via the Find a Drug page) or by contacting member services at (800) 310-2835 and having the form faxed directly to the office. To ensure that you are submitting the correct form, please search the requested drug on our online Drug Formulary, accessible via the Find a Drug page, to obtain the appropriate prior-authorization form. Review request for newly approved drugs and quantity limitations. If a physician requests an FDA approved medication for a non-FDA approved disease state/condition, or dosing schedule, you must submit at least 3 peer-reviewed journal articles or abstracts; a national or published Clinical Guideline; and/or published information regarding current standard of care. Please click on the form that you need and it will open in PDF format so you can print it.
Massachusetts Standard Form for Hepatitis C Medication Prior Authorization Requests
Massachusetts Standard Form for Medication Prior Authorization Requests
Massachusetts Standard Form for Synagis® Prior Authorization Requests
Medication Request Form (MRF) for Prior Authorization
Member Prescription Reimbursement Form
Prescription Drug Program Mail Service Form

Employers/Brokers

Employer Group Application Employer Group Agreement
Enrollment / Add / Termination Form Enrollment / Add / Termination Form (Spanish) Supplemental Enrollment Form Commercial Enrollment Template
Employer Group Medicare Application Group Medicare Supplement Plan Enrollment / Termination Form
Group Authorization for Brokerage Representative(s)
Domestic Rider
Broker Compensation Electronic Funds Transfer Form (EFT)
HIPAA Special Enrollment Rights
HIPAA Special Enrollment Rights FAQ's
COBRA Continuation Coverage
2025 Medicare Part D Creditable Coverage Rider Information
Small Group Template Small Group Caveats
Understanding Your Invoice