To get the best Web site experience,
please enable JavaScript
in your browser’s preferences.
888-257-1985
Call us at
About Network Health
Contact Us
Search
Home
Providers
Forms
You’ll find all the forms you need to do business with us right here.
Medical forms
Behavioral health forms
Pharmacy forms
Claims forms
General forms
Forms for your patients
Downloads
Medical forms
Jump to top
Standardized Prior Authorization Request Form
(PDF) — This form allows you to request prior authorization for medical services.
Standardized Durable Medical Equipment (DME) and Medical Supplies Prior Authorization Request Form
(PDF)
Combined MCE Behavioral Health Provider/Primary Care Provider Communication Form
(PDF)
Consent to Exchange Information Form
(PDF) — This form allows your patient to give consent for two providers to exchange information about their care.
Prenatal Registration Form
(PDF)
Universal Health Plan/Home Health Authorization Form
(PDF)
Combined MassHealth MCO Medical Necessity Review Form for Enteral Nutrition Products (Special Formula)
(MS Word doc)
Medical Provider Information Form
(MS Word doc)
Behavioral health forms
Jump to top
Combined MCE Behavioral Health Provider/Primary Care Provider Communication Form
(PDF)
Consent to Release Information Form
(PDF) — This form allows us to release information about your patient to selected individuals or organizations.
Consent to Exchange Information Form
(PDF) — This form allows your patient to give consent for two providers to exchange information about their care.
Crisis Prevention Plan (CPP) Worksheet Form
(PDF)
Adverse Incident Report Form
(PDF)
Authorization Request for Psychological Testing Form
(PDF)
Combined MCO Outpatient Review Form
(PDF)
Community Service Agency (CSA) Notification Form
(PDF)
Intensive Care Coordination (ICC) Discharge Form
(PDF)
Acute Treatment Services (ATS) Admission Notification Form
(PDF)
In-home Therapy (IHT) Discharge Form
(PDF)
Outpatient Behavioral Health Outcome Tool Selection Form
(PDF)
Behavioral Health Provider Information Form
(MS Word doc)
Out-of-network Outpatient Prior Authorization Request Form
(MS Word doc)
Autism Spectrum Disorder Services Prior Authorization Request Form
(MS Word doc)
Pharmacy forms
Jump to top
Caremark Enrollment Form
(PDF)
Cymbalta (duloxetine) Medication Request Form
(PDF)
Hepatitis C Medication Request Form
(PDF)
HMG-CoA Reductase Inhibitors Medication Request Form
(PDF)
MedImpact Medication Request Form
(PDF)
Non-sedating Antihistamines Medication Request Form
(PDF)
Proton Pump Inhibitors Medication Request Form
(PDF)
Sphingosine 1-Receptor Modulators Medication Request Form
(PDF)
Suboxone (buprenorphine/naloxone) Medication Request Form
(PDF)
Synagis (palivizumab) Medication Request Form
(PDF)
Vivitrol (naltrexone) Medication Request Form
(PDF)
Claims forms
Jump to top
Electronic Data Interchange (EDI) Intake Form
(PDF)
CMS 1500 Form
(PDF)
UB04 Form
(PDF)
Provider Check Tracer Request Form
(MS Word doc)
Request for Claim Review Form
(PDF)
General forms
Jump to top
Medical Provider Information Form
(MS Word doc)
Behavioral Health Provider Information Form
(MS Word doc)
Massachusetts Substitute W-9 Form
(PDF)
Third Party Liability Indicator Form
(PDF) — This form applies to MassHealth members only
Forms for your patients
Jump to top
Primary Care Provider (PCP) Selection/Change Form
(PDF)
Authorized Representative Form
(PDF)
External review form from the MassHealth Board of Hearings
for
Network Health Together
®
(MassHealth) members — Use this form to request an external review only after we have made a decision on a first- or second-level Adverse Action Appeal.
External review form from the Office of Patient Protection
for
Network Health Forward
®
(Commonwealth Care) and
Network Health Choice
(an individual and small-group plan) members — Use this form to request an external review after we have made a decision on an Adverse Determination Appeal or concurrent review.
External review form from the Department of Unemployment Assistance
for
Network Health Extend
™
(Medical Security Program) members — Use this form to request an external review after we have made a decision on an Adverse Determination Appeal or concurrent review.
Share us
888-257-1985
Call us
Contact us
About Network Health