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!

• Attestation for OB/GYN Provider Status Form - FCHP MassHealth (pdf, 180 KB)
• Health Insurance Claim Form (pdf, 272 KB)
• Material Request Form
• Infertility Services Pre-Authorization Request Form (Medical and Pharmacy) (pdf, 146 KB)
• Outpatient Care Services Referral Form (pdf, 44 KB)
• Caremark Pharmacy Fax Form (pdf, 6 MB)
• Caremark Pharmacy Fax Form - Mail service (new prescriptions) (pdf, 272 KB)
• Pharmacy Prior Authorization Form (pdf, 577 KB)
• Plan Determination Form (pdf, 912 KB)
• Provider Claims Adjustment Request Form (pdf, 351 KB)
• Provider Appeals Request Form (pdf, 646 KB)
• Provider Update Form (pdf, 87 KB)
• Request for Preauthorization Form (pdf, 428KB)
• Skilled Nursing Facility Admission Form (pdf, 442 KB)
• Skilled Nursing Facility Request for Continued Stay Form (pdf, 451 KB)
• Special Formula Medical Necessity Form (pdf, 53 KB)
• Third Party Liability Indicator Form (pdf, 33KB)
• 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!