Forms

These documents are listed in alphabetical order.

General Use Prior Authorization Form 01/2008

Health Disclosure Authorization 08/2013

Hysterectomy Form MA-39 09/2005

Instructions MA-39

Individual Adjustment Request 09/2024

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 12/2018

MA-3 02/2019

MA-37 Abortion Services Physician Certification Form 09/2021

MA-37 Instructions

MA-39 Hysterectomy Form 09/2005

Instructions MA-39

MATH Web Portal Link Request 12/2018

Medicaid Attestation Form on the Appropriateness of the Qualified Clinical Trial 08/2023

Medicaid Form Order Sheet 05/2012

Medical-Surgical Prior Authorization Request 11/2018

Medical History Authorization Form 12/2005

Medication Assisted Treatment (MAT) Member Form 11/2021

Mental Health 72-Hour Presumptive Eligibility Program Provider Enrollment Addendum 08/2008

Montana Medicaid Hearing Aid Certificate of Medical Necessity 06/2023

Montana Medicaid Hearing Aid Prior Authorization Request Form 06/2023

Nursing Facility Claim Form MA-3   02/2019

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 Therapeutic Home Visit in Excess of 72 Hours DPHHS-SLTC-042 Hours 07/2022

Nursing Facility Request for Nursing Home Bed Reservation During Resident's Temporary Hospitalization DPHHS-SLTC-052 07/2022

Nursing Facility Request for Therapeutic Home Visit Bed Reservation DPHHS-SLTC-041 07/2022

Nursing Facility Staffing Report 08/2016

Nursing Facility Staffing Report Instructions

Orthodontia Prior Authorization Request Form 06/2023

Orthodontia Prior Authorization Request Form Instructions 06/2023

Orthognathic Surgery Prior Authorization Request 04/2017

Paperwork Attachment Cover Sheet 10/2024

Permission to Bill Medicaid 10/2006

Physician Assistant Independent Practice Attestation (07/2025)

Place of Service Codes (Link to CMS Website).

Private Duty Nursing Services Prior Authorization Forms for Agencies 02/2025

Private Duty Nursing School Based Services Request Form 02/2025

Provider Enrollment (link to the Provider Enrollment page on this website)

Request for Blanket Denial for TPL 04/2014

School-Based Services CSCT Audit Checklist 05/2013

School-Based Services Personal Care Paraprofessional Child Profile 08/2018

School-Based Services Personal Care Paraprofessional Task and Hour Guide 08/2018

Sterilization Forms

Team Care Provider/Pharmacy Change Form  10/2024

Request a provider or pharmacy change for a member.

Team Care Referral Form 10/2024

Providers may use this form when referring a member to the Team Care Program.

Therapy Order Template 04/2024

Form is to be printed on provider's letterhead

TPL Blanket Denial Request 04/2014

Trading Partner Agreement  

UB-04 / CMS-1450 Claim Form

Web Portal Link Request for the Montana Access to Health Web Portal 12/2018

Well Child Screen Recommendations 07/2014

W-9 Form

This version (Rev. 03/2024) is approved for use.