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Authorization

Applied Behavior Analysis Service Request Form

Assisted Reproductive Technology (ART) Services Form

Automatic Fax-Back Program: Request Form

Behavioral Health - Level of Care Request Supplemental Form

Use this supplemental form as a cover sheet for the standardized Mass Collaborative form.

Continuation of Care Request for Providers Disengaging from our Networks

Continuity/Transition of Care Request

Esketamine Nasal Spray and Intravenous Ketamine for Treatment Resistant Depression: Prior Authorization Request Form

Habilitative Therapy Request Form for HMO Members

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

Handicapping Labio-Lingual Deviations (HLD Index 4)

Initial Precertification Form for SNF/Rehab/LTCH

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.

Managed Care Out-of-Network Request Form

Pre-Authorization for Non-Emergent Ground Ambulance Transport

Pre-Certification / Pre-Authorization Request

Prior Authorization Request for Medically Necessary Orthodontia Services for Pediatric Essential Health Benefits

Psychological and Neuropsychological Assessment Supplemental Form

Use this supplemental form as a cover sheet for the standardized Mass Collaborative form.

Repetitive Transcranial Magnetic Stimulation Supplemental Form

Use this supplemental form as a cover sheet for the standardized Mass Collaborative form.

SNF/Rehab/LTCH Clinical Recertification Request Form

Short-Term Rehabilitation Speech Therapy Extension Request Form

Short-Term Rehabilitation Therapy Extension Request 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.