Forms

• 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
• Baystate Health Massage Reimbursement Form (FOR BAYSTATE HEALTH EMPLOYEES ONLY)
• 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)

• 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

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.

• 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 

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

• Advanced Care Planning Toolkit & Forms

Behavioral Health

• 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