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 12/2017 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 Buprenorphine/Naloxone MAT Attestation Form 04/2021 CSCT Contractor/Team Change Form 11/2018 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 04/2016 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 06/2019 DME CMN Over $1,000 10/2014 DME CMN Oxygen CMS-484 06/2019 DME CMN Parenteral Therapy 10/2014 DME CMN Pneumatic Compression Devices CMS-846 06/2019 DME CMN Pressure-Reducing Surfaces 10/2014 DME CMN Prosthetics & Orthotics 10/2014 DME CMN Seat Lift Mechanism CMS-849 1 06/2019 DME CMN Continuation Form CMS-854 06/2019 DME CMN Transcutaneous Electrical Nerve Stimulators (TENS) CMS-848 06/2019 DME Enteral and Parental Nutrition CMS-10126 06/2019 DME Information Form External Infusion Pumps CMS-10125 06/2019 DME Medicaid Prior Authorization Form 10/2014 Drug Prior Authorization Request Form - Outpatient Pharmacy 12/2018 Electronic Funds Transfer (EFT) Authorization Agreement 04/2020 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. Enrollment Forms This is a link to the complete provider enrollment package. EPSDT Prior Authorization Request 12/04/2020 Essential for Employment Sample You must request the actual document from your local Office of Public Assistance. Eyeglass Additional Feature and Contact Lens Prior 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 Hearing Aid CMN Form 07/2003 Hearing Aid PA Request 01/2008 Hepatitis C Prior Authorization Form 01/2020 Home Health Initial Authorization Request 08/2016 Home Health Prior Authorization for Extended Services Request 08/2016 Home Infusion Therapy Prior Authorization Request Form 11/2017 Hysterectomy Form MA-39 09/2005 Instructions MA-39 Adjustment Request Individual 12/2017 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 Forms M – O MA-3 02/2019 MA-37 Abortion Services Physician Certification Form 03/2015 MA-37 Instructions MA-39 Hysterectomy Form 09/2005 Instructions MA-39 MATH Web Portal Link Request 12/2018 Medicaid Form Order Sheet 05/2012 Medicaid Medical-Surgical Prior Authorization Request 11/2018 Medical History Authorization Form 12/2005 Medication Assisted Treatment (MAT) Member Form 07/2018 Mental Health Services Plan Addendum 10/2014 Mental Health Services Plan Clinical Eligibility Form 08/2018 Mental Health Services Plan Non-Medicaid Enrollment Application 08/2018 Mental Health 72-Hour Presumptive Eligibility Program Provider Enrollment Addendum 08/2008 Non-Covered Services Agreement 07/2012 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 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 Orthodontia HLD Index and Prior Authorization Treatment Plan 09/2013 Orthognathic Surgery Prior Authorization 04/2017 Ownership Update Provider Disclosure Statement rev 10/2018 Forms P – Z Paperwork Attachment Cover Sheet 04/2020 Permission to Bill Medicaid 10/2006 Place of Service Codes (Link to CMS Website). Prior Authorization Request - Out of State Inpatient Admissions 04/2018 Prior Authorization Request Buprenorphine Containing Products 04/08/2021 Prior Authorization Request EPSDT 04/06/2017 Prior Authorization Request Eyeglass and Contact Lens 04/2017 Prior Authorization Request Growth Hormone 11/2018 Prior Authorization Request Hepatitis C Treatment 01/2020 Prior Authorization Request for Home Infusion Therapy 11/2017 Prior Authorization Request Medicaid Medical-Surgical 11/2018 Prior Authorization Request for Orkambi® 08/2018 Prior Authorization Request Orthognathic Surgery 04/2017 Prior Authorization Request Sublocade® 03/22/2021 Prior Authorization Request Vivitrol® 04/08/2021 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 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. Provider Enrollment (link to the Provider Enrollment page on this website) 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 08/2018 School-Based Services Personal Care Paraprofessional Task and Hour Guide 08/2018 Sterilization Forms Sterilization Form HHS 687 06/2019 Instructions for Consent for Sterilization Team Care Referral Form 01/2020 Team Care Provider/Pharmacy Change Form 01/2020 Request a provider or pharmacy change for a member. T-HIP Member Opt Out Form 02/2019 T-HIP Provider Referral Form 02/2019 T-HIP Tier Request Form - Please request this form from the T-HIP Specialist at the Department. TPL Blanket Denial Request 07/2012 Trading Partner Agreement Click here for the complete provider enrollment package. 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. 12/2011) is approved for use. Click here for the complete provider enrollment package.