Forms
When you’re in need of a standard FCHP form, this is the place. The forms most frequently needed by FCHP providers are listed below—simply click, download and print!
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Attestation for OB/GYN Provider Status Form - FCHP MassHealth (pdf, 180 KB)
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Caremark Pharmacy Fax Form (pdf, 6 MB)
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Caremark Pharmacy Fax Form - Mail service (new prescriptions) (pdf, 272 KB)
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Disease Management - Case Management Referral Form (pdf, 34 KB)
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Health Insurance Claim Form (pdf, 272 KB)
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Infertility Services Prior Authorization Request Form (Medical and Pharmacy) (pdf, 44 KB)
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Material Request Form
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MCE Behavioral Health Provider/Primary Care Provider Communication Form (pdf, 123 KB)
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Pharmacy Prior Authorization Forms
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Plan Determination Form (pdf, 912 KB)
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Provider Update Form (pdf, 87 KB)
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Request for Claim Review Form and Reference Guide (Replaces "Provider Claims Adjustment Request Form" and "Provider Appeals Request Form")
- Quit To Win referral forms
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Request for Prior Authorization Form (pdf, 194 KB)
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Skilled Nursing Facility Admission Form (pdf, 36 KB)
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Skilled Nursing Facility Request for Continued Stay Form (pdf, 38 KB)
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Special Formula Medical Necessity Form (pdf, 53 KB)
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Third Party Liability Indicator Form (pdf, 33KB)
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Universal Health Plan/Home Health Authorization Form (pdf, 112 KB)
Is there an additional form or two you would like listed here? Let us know!