Administrative Resources

Type	Title
	Bulletin202115RelaxationofPriorAuthorizationandCredentailingProcessesinResponsetotheStaffingandResou
	Federal Required Disclosures Form (Individual Practitioners or Group Practices)
	Federal Required Disclosures Form (Other than Individual Practitioners or Group Practices)
	Level of Need Transportation Form - SCO Only
	Medicare Hospital Inpatient Rights Notice
	Non-Participating Provider Activation Form
	Paper Remittance Request Form
	Pediatric Primary Care Services at Boston Medical Center
	Provider Quick Reference and Contact Information Guide
	Waiver of Liability for Non-Participating Senior Care Options Providers Form

Type	Title	Plan Type
	Appointment of Representative Form (English) - SCO	SCO
	Appointment of Representative Form (Spanish) - SCO	SCO
	Care Management Referral Form - SCO	SCO
	Coordination of Benefits Indicator Form - SCO	SCO
	Senior Care Options Member Benefit Documents	SCO
	Care Management Referral Form - QHP	QHP
	Combined MCE Behavioral Health Provider PCP Communication Form - QHP	QHP
	ConnectorCare-QHP Member Benefit Documents	QHP
	Intensive Clinical Management Release of Information Form - QHP	QHP
	Member PCP Transfer Request Form - QHP	QHP
	PCP Selection Form - QHP	QHP
	Involuntary Member Disenrollment Request Form	MassHealth
	Appeals Representative Authorization Form - MassHealth	MassHealth
	Behavioral Health Care Management Referral Form	MassHealth
	Care Management Referral Form - MassHealth ACO	MassHealth
	Care Management Referral Form - MassHealth MCO	MassHealth
	Combined MCE Behavioral Health Provider PCP Communication Form - MassHealth	MassHealth
	Coordination of Benefits Indicator Form - MassHealth	MassHealth
	Intensive Clinical Management Release of Information Form - MassHealth	MassHealth
	MassHealth Member Materials	MassHealth
	Member PCP Transfer Request Form - MassHealth	MassHealth
	Notification of Birth Form - MassHealth	MassHealth
	PCP Selection Form - MassHealth	MassHealth

Type	Title
	Non-Participating Provider Activation Form
	HCAS Provider Enrollment Form
	Letter of Interest Request Form
	Locum Tenens Credentialing Form
	Provider Change and Termination Form
	Provider Data Form
	Standardized Provider Information Change Form

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