Forms Forms These documents are listed in alphabetical order. A – C D – F G – L M – O P – Z Forms A – C Abortion Services Physician Certification Form MA-37 03.2015 MA-37 Instructions Address Correction Form for Providers 02.2015 Pay-To/1099 changes must be accompanied by a completed W-9 form. This form must be printed and signed, and may be mailed or faxed. Adjustment Request Individual 09.2016 This form may be completed online; however, you must print, sign, and date before mailing to the address indicated. Ambulance Trip Log 01.2008 Attachment Cover Sheet for Paperwork 05.2015 Authorization for Health Disclosure 03.2003 Blanket Denial Request for TPL 04.2014 Breakage and Loss, Medicaid 06.2015 CMS-1450 / UB 04 03.2007 CMS-1500 (02.12) As of April 1, 2014, this is the accepted version of the CMS-1500. Contact Lens and Eyeglass Additional Feature Prior Authorization Request 01.2016 Montana Medicaid and HMK Cultural and Language Services Invoice 04.2015 Cultural and Language Services Policy 05.2015 Forms D – F Dental Claim Form 2012 04.2014 Dental Emergency Services Form 07.2013 All fields must be completed and the form must be signed, dated, and attached to an ADA Dental claim form. Dental HLD Index and Prior Authorization Treatment Plan 09.2013 DME CMN Augmentative Communication Device 10.2014 DME CMN Enteral Therapy 10.2014 DME CMN EPSDT Nutrition 10.2014 DME CMN Hospital Bed 10.2014 DME CMN Manual Wheelchair 10.2014 DME CMN Motorized Wheelchair 10.2014 DME CMN Osteogenesis Stimulators CMS-847 03.2014 DME CMN Over $1,000 10.2014 DME CMN Oxygen CMS-484 11.2011 DME CMN Parenteral Therapy 10.2014 DME CMN Pneumatic Compression Devices CMS-846 11.2011 DME CMN Pressure-Reducing Surfaces 10.2014 DME CMN Prosthetics & Orthotics 10.2014 DME CMN Seat Lift Mechanism CMS-849 11.2011 DME CMN Continuation Form CMS-854 09.2005 DME CMN Transcutaneous Electrical Nerve Stimulators (TENS) CMS-848 09.2005 DME Information Form External Infusion Pumps CMS-10125 03.2014 DME Medicaid Prior Authorization Form 10.2014 Drug Prior Authorization Request Form 05.2014 Electronic Funds Transfer (EFT) & Electronic Remittance Advice (ERA) Authorization Agreement 01/17/2016 A form is required for each NPI requiring a change. Changes will be made to all files under that NPI. Do not send voided checks or deposit slips. Click here for the complete provider enrollment package. Emergency Dental Services Form 07.2013 All fields must be completed and the form must be signed, dated, and attached to an ADA Dental claim form. Enrollment Forms This is a link to the complete provider enrollment package. EPSDT Prior Authorization Request 04/06/2017 Essential for Employment Sample You must request the actual document from your local Office of Public Assistance. Exception to 24 Sessions Request Form 08.2015 Eyeglass Additional Feature and Contact Lens Prrior Authorization Request Eyeglass and Contact Lens 04/2017 Montana Medicaid and HMK Forms G – L General Use Prior Authorization Form 01.2008 Health Disclosure Authorization 08.2013 Health Improvement Program Provider Referral Form 09.2015 Providers should complete the form and fax it to 406.444.1861. Healthy Montana Kids (HMK) Eyeglass Rx Form 06.2015 Hearing Aid CMN Form 07.2003 Hearing Aid PA Request 01.2008 Home Health Initial Authorization Request 08.2016 Home Health Prior Authorization for Extended Services Request 08.2016 Home Infusion Therapy Prior Authorization Request Form 12.2013 Hospice Client Election of Benefits 07.2004 Hospice Physician Certification Statement 07.2004 Hysterectomy Form MA-39 09.2005 Instructions MA-39 Individual Adjustment Request Individual 09.2016 This form may be completed online; however, you must print, sign, and date before mailing to the address indicated. Link Request, Montana Access to Health Web Portal 04.2014 Forms M – O MA-3 Nursing Home Claim Form 10.2006 MA-37 Abortion Services Physician Certification Form 03.2015 MA-37 Instructions MA-38 Sterilization Form 09.1998 Instructions MA-38 MA-39 Hysterectomy Form 09.2005 Instructions MA-39 MA-5 Prescription Claim Form 09.2008 Medicaid and HMK Plus HIP Provider Referral Form 02.2015 Providers should complete the form and fax it to 406.444.1861. Medicaid Eyeglass Breakage and Loss 06.2016 Medicaid Eyeglass Rx Form 06.2015 Medicaid Form Order Sheet 05.2012 Medicaid Medical-Surgical Prior Authorization Request 04/2017 Medical History Authorization Form 12.2005 Mental Health Services Plan Addendum 10.2014 Mental Health Services Plan Clinical Eligibility Form 06.2009 Mental Health Services Plan Non-Medicaid Enrollment Application 12.2008 Mental Health Services Plan Non-Medicaid Enrollment Application LARGE PRINT 12.2008 Mental Health 72-Hour Presumptive Eligibility Program Provider Enrollment Addendum 08.2008 Nursing Facility Claim Form MA-3 10.2006 Nursing Facility Level of Care Determination DPHHS-SLTC 086 01.2011 Nursing Facility Level I Screen DPHHS-SLTC 145 01.2011 Nursing Facility Notice of Transfer or Discharge 08.2016 Nursing Facility Request for Bed Reservation for Home Visit in Excess of 72 Hours 08.2016 Nursing Facility Request for Nursing Home Bed Reservation During Resident's Temporary Hospitalization DPHHS-SLTC 052 08.2016 Nursing Facility Request for Therapeutic Home Visit Bed Reservation DPHHS-SLTC 041 08.2016 Nursing Facility Staffing Report 08.2016 Nursing Facility Staffing Report Instructions Optometric Breakage and Loss Form 06.2015 Optometric HMK Rx Form 06.2015 Optometric Medicaid Rx Form 06.2015 Optometric Prior Authorization Request Eyeglass and Contact Lens 01.2016 Montana Medicaid and HMK Orthodontia HLD Index and Prior Authorization Treatment Plan 09.2013 Orthognathic Surgery Prior Authorization 04/2017 Ownership Update Provider Disclosure Statement Ownership Update Provider Disclosure Statement Instructions Forms P – Z Paperwork Attachment Cover Sheet 09/2015 Permission to Bill Medicaid 10/2006 Place of Service Codes 11/2012 Prior Authorization Request Buprenorphine Containing Products 12/12/2016 Prior Authorization Request EPSDT 04/06/2017 Prior Authorization Request Eyeglass and Contact Lens 04/2017 Prior Authorization Request Growth Hormone 12/12/2016 Prior Authorization Request Hepatitis C Treatment 10/2016 Prior Authorization Request Form Drug 05/2016 Prior Authorization Request for Home Infusion Therapy 12/2013 Prior Authorization Request Medicaid Medical-Surgical 04/2017 Prior Authorization Request for Orkambi 10/2016 Prior Authorization Request Orthognathic Surgery 04/2017 Provider Referral Fax Form for Team Care 01/2008 Private Duty Nursing Authorization Request for Agencies 12/2015 Private Duty Nursing Authorization Request for Schools 12/2015 Provider Address Correction Form 02/2015 Pay-To/1099 changes must be accompanied by a completed W-9 form. This form must be printed and signed, and may be mailed or faxed. Provider Enrollment 10/2014 Request for Blanket Denial for TPL 04/2014 Request for Drug Prior Authorization 05/2014 School-Based Services CSCT Audit Checklist 05/2013 School-Based Services Personal Care Paraprofessional Child Profile 05/2013 School-Based Services Personal Care Paraprofessional Task and Hour Guide 08/2003 SMAC Pricing Inquiry Worksheet 06/2013 Sterilization Form MA-38 11/2016 Instructions MA-38 HHS 687 Consent For Sterilization 11/2016 Team Care Referral Form 12/2013 Team Care Provider/Pharmacy Change Form 12/2013 Request a provider or pharmacy change for a member. Therapy Sessions, Exception to 24 Sessions Request Form 08/2015 TPL Blanket Denial Request 07/2012 Trading Partner Agreement 10/2014 Click here for the complete provider enrollment package. UB-04 / CMS-1450 Claim Form Link Request, Montana Access to Health Web Portal 04/2014 Well Child Screen Recommendations 07/2014 W-9 Form This version (Rev. 12/2011) is approved for use. Click here for the complete provider enrollment package.