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 Prior Authorization (PDF)
• MCNA Dental Therapeutic Treatment with Anesthesia Prior Auth Request
• Notice of Pregnancy NOP (PDF) for provider use
• Outpatient Medicaid Authorization (PDF)
• Outpatient Medicaid Authorization PT/OT/ST (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 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)
• Intensive Outpatient Mental Health/Chemical Dependency Form (PDF)
• Medicaid Rehab Option (MRO) Request (PDF)
• Neuro Psychological Testing OTR Form (PDF)
• Outpatient Treatment Request (OTR) General BH (PDF)
• Outpatient Treatment Request (OTR) Non-Par (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