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Authorization

Starting July 16, 2024, this form will no longer be available on Provider Central. Please use the Massachusetts Standard Form for Applied Behavior Analysis Services Prior Authorization Requests.

This file combines the Blue Cross cover sheet with the Mass Collaborative form.

Use this form ONLY for habilitative serviceshabilitative services. Habilitation services are defined as health care services that help a person keep, learn, or improve skills and functioning for daily living.

Please do not use this form for members in long-term care requiring physical, occupational, or speech therapy. For authorization instructions, visit Outpatient Rehabilitation Therapy.

Please do not use this form for members in long-term care requiring physical, occupational, or speech therapy. For authorization instructions, visit Outpatient Rehabilitation Therapy.

This file combines the Blue Cross cover sheet with the Mass Collaborative form.

This file combines the Blue Cross cover sheet with the Mass Collaborative form.

Please file this form one week prior to the last covered service. For more instructions on how to complete the form, refer to our Guide.