These documents are listed in alphabetical order.

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

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

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 04/2017

Paperwork Attachment Cover Sheet 04/2020

Permission to Bill Medicaid 10/2006

Place of Service Codes (Link to CMS Website).

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 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.