These documents are listed in alphabetical order.

Dental 2019 Claim Form Sample 10/2021

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

Electronic Funds Transfer (EFT) Authorization Agreement 04/2022

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.

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

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 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 11/2021

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 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 HLD Index and Prior Authorization Treatment Plan 09/2013

Orthognathic Surgery Prior Authorization 04/2017

Ownership Update Provider Disclosure Statement rev 10/2018

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 Eyeglass and Contact Lens 04/2017

Prior Authorization Request Medicaid Medical-Surgical 11/2018

Prior Authorization Request Orthognathic Surgery 04/2017

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

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 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.