Department of Public Health and Human Services

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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 04/2017

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

Buprenorphine Containing Products PA 11/2017

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

Custom Agreement for Medicaid Non-Covered Services 07/2012

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.

Eyeglass Additional Feature and Contact Lens Prrior Authorization Request Eyeglass and Contact Lens 04/2017
Montana Medicaid and HMK

Forms G – L

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

MATH Web Portal Link Request 10/2017

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

Non-Covered Services Agreement 07/2012

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 rev 10/2017

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 11/2017

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

T-HIP Member Opt Out Form 10/2017

T-HIP Provider Referral Form 10/2017

T-HIP Tier Request Form 10/2017

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.