Forms
These documents are listed in alphabetical order.
Abortion Services Physician Certification Form MA-37 09/2021
Advanced Beneficiary Notice for Noncovered Services and Costs Exceeding Annual Limits 09/2023
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
CMS-1500 Claim Form Sample and Instructions 01/2025
CSCT Contractor/Team Change Replacement 09/2022
Dental 2019 Claim Form Sample 10/2021
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 02/2025
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.
EPSDT Prior Authorization and Certificate of Medical Necessity Form 03/2025
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
General Use Prior Authorization Form 01/2008
Health Disclosure Authorization 08/2013
Home Health Initial Authorization Request 08/2016
Home Health Prior Authorization for Extended Services Request 08/2016
Hysterectomy Form MA-39 09/2005
Individual Adjustment Request 09/2024
This form may be completed online; however, you must print, sign, and date before mailing to the address indicated.
MA-3 02/2019
MA-37 Abortion Services Physician Certification Form 09/2021
MA-39 Hysterectomy Form 09/2005
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 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
Paperwork Attachment Cover Sheet 10/2024
Permission to Bill Medicaid 10/2006
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
- Sterilization Form HHS 687 07/2024
- Instructions for HHS 687 07/2024
Suboxone (buprenorphine/naloxone) Film MOUD Provider Attestation Form 03/2024
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
Web Portal Link Request for the Montana Access to Health Web Portal 12/2018
Well Child Screen Recommendations 07/2014
This version (Rev. 03/2024) is approved for use.