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

Drug Prior Authorization Request Form - Outpatient Pharmacy 12/2018

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


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

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.