Practice Improvement Resource Center (PIRC)
Physical Health Forms
- Hearing Aid Authorization Request MS-76 (search MS-76)
- Home Health Authorization Request MS-72 (search MS-72)
- Informed Consent for Hysterectomies and Completion Instructions (PDF)
- Inpatient Medicaid Prior Authorization (PDF)
- MCNA Dental Therapeutic Treatment with Anesthesia Prior Auth Request
- Dental Prior Authorization List (PDF)
- Notice of Pregnancy NOP (PDF) for provider use
- Outpatient Medicaid Prior Authorization (PDF)
- Outpatient Medicaid Prior Authorization PT/OT/ST (PDF)
- Outpatient Treatment Request (OTR) Tip Sheet (PDF)
- PCP Change (PDF) for provider use
- Physician's Report on Hearing Loss DM-5H (search DM-5H)
- Provider Claim Appeal (PDF)
- Provider Reconsideration (PDF)
- PT/OT/ST Authorization FAQ (PDF)
- PT/OT/ST Authorization Tips
- PT/OT/ST Authorization Transition Training Presentation (PDF)
- Sterilization Consent Form and Completion Instructions (PDF)
- Sterilization Consent Form English (PDF)
- Sterilization Consent Form Spanish (PDF)
Behavioral Health Forms
- Applied Behavioral Analysis (ABA) Form (PDF)
- ABA Behavior Assessment and Plans Tip Sheet (PDF)
- ABA Caregiver Training Tip Sheet (PDF)
- ABA Coordination of Care Tip Sheet (PDF)
- ABA Medication Management Tip Sheet (PDF)
- ABA Outpatient Treatment Request (OTR) Tip Sheet (PDF)
- ABA Prescription Fulfillment Tip Sheet (PDF)
- ABA Transition Planning Tip Sheet (PDF)
- Behavioral Health Bulletins
- Certificate of Need for Psychiatric Residential Treatment Facility (PDF)
- Critical Incident Report Form (PDF)
- Disease Management Referral (PDF)
- Electroconvulsive Therapy (ECT) Form (PDF)
- Inpatient Medicaid Prior Authorization (PDF)
- Intensive Outpatient Mental Health/Chemical Dependency Form (PDF)
- Medicaid Rehab Option (MRO) Request (PDF)
- Neuro Psychological Testing OTR Form (PDF)
- Outpatient Medicaid Prior Authorization (PDF)
- Outpatient Treatment Request (OTR) General BH (PDF)
- Outpatient Treatment Request (OTR) Non-Par (PDF)
- Outpatient Treatment Request (OTR) Tip Sheet (PDF)
- Provider Claim Appeal Form (PDF)
- Provider Incomplete Information Fax (PDF)
- Provider Reconsideration Form (PDF)
- Wellness Plan (PDF)
General Provider Information
- DHHS Heritage Health Resources
- DHHS Provider Bulletin PB 15-54 Provider Screening and Enrollment - Maximus Information (PDF)
- DHHS Provider Bulletin PB 16-26 Continuity of Care (PDF)
- DHHS Provider FAQs (PDF)
- Enhanced Ambulatory Patient Groups (EAPGs) Training Overview (PDF)
- Incentives Statement
- Limitations on Provider Marketing (PDF)
- Maximus Provider Enrollment Portal