Forms

Here you'll find printable documents and forms available in PDF and/or text format. To download a free version of Adobe Reader, click on the icon at the bottom of this page.

Click on a section heading below for easy access to specific forms:

Administrative Forms

• Bone Density Equipment Information Form
• Chapter 305 Compliance Form
• Member PCP Change Request Form
• Practitioner Attestation Practice Site Standards Form
  
• Provider Information Change Form - Update your demographic information
• Provider Inquiry Line Automation Guide
  
• Provider Payment Dispute Cover Sheet
  
• Provider Payment Dispute Cover Sheet-CareLink CIGNA as Primary Administrator
  
• Provider Payment Dispute Cover Sheet-CareLink Shared Administration
  
• Referral Waiver Form
  
• Request for Out of Plan ID Number Form
• Returned Funds Form
  
• Supply Order Form
• Universal Provider Request for Claim Review Form

Authorization Forms

• ABA Initial Services Request —Assessment and Treatment Planning (H0031) ONLY
• ABA Initial Services Request
• Anti-Obesity Authorization Form
• Autism Services: PT, OT and ST Authorization Form
• Continuity of Care Review for Members of Tiered or Limited Network Plans: Massachusetts Request Form
• Continuous Glucose Monitoring System Prior Authorization Request Form
• Continuous Passive Motion Machine Form
  
• Guide for Completing Mental Health Care Service Requests Using IVR
  
• Heart Transplant Request for Coverage Form
• iCanChange® Authorization Form
• Incivek® Coverage Request Form
• Infertility Authorization Form
• Infertility Treatment Summary Form
• Intestinal and Multivisceral Request for Coverage Form
• Kidney Transplant Request for Coverage Form
• Liver Transplant Request for Coverage Form
• Lung Transplant Request for Coverage Form
• Mental Health Provider Availability Form
• MHQP Obstetrical Risk Assessment Form
• Non-Emergency Ambulance Transportation: Ground Medical Necessity Form
• Occupational Therapy Authorization Form
• Orthognathic Surgery Authorization Form
• Pancreas Transplant Request for Coverage Form
• Preferred Drug List
• Physical Therapy Authorization Form
• Preimplantation Genetic Determination Form
• Preregistration Form
• Psychological/Neuropsychological Testing
• Speech Therapy Evaluation and Authorization Form
• Stem Cell Transplant Authorization Form
• Transcranial Magnetic Stimulation (rTMS) Prior Authorization Form- Commercial
• Uniformed Services Family Health Plan Occupational Therapy Completion Guide and Authorization Form
  
• Uniformed Services Family Health Plan Physical Therapy Program Guidelines and Authorization Form
• Universal Health Plan/Home Health Authorization Form (UHHA)
• Universal Pharmacy Form
• Upper GI Endoscopy Authorization Form
• Victrelis™ Coverage Request Form
• Video Capsule Endoscopy Authorization Form
• Viscosupplement Authorization and Prescription Form

Clinical Forms

• Acute Inpatient Continued Stay Clinical Information Form
• Extended Care Inpatient Continued Stay Clinical Information Form - Additional
• Extended Care Inpatient Continued Stay Clinical Information Form - Initial
• SNF Discharge Planning Form
• Tufts Medicare Preferred SNF Review Form
  

Credentialing Forms

• HealthCare Administrative Solutions (HCAS) Resources
• Mental Health Provider Credentialing Forms
• Board Certified Behavior Analyst Provider Credentialing Forms

Tufts Health Plan Website Registration Forms

• Provider Change Access Administrator Form
• Provider Registration Authorization Form
• Provider Unit Change Access Administrator Form
• Provider Unit Registration Authorization Form

Tufts Medicare Preferred HMO Forms

• Coverage Determination and Prior Authorization for Medicare Part B or Part D
• Denial of Coverage and Expedited Approval Form (01/2013)
• Denial of Coverage and Expedited Approval Form Instructions (01/2013)
• SNF/HHA/CORF Discharge Summary Form (revised 11/2009) Word
• SNF/HHA/CORF Discharge Summary Form Instructions (revised 11/2009) Word
• SNF Discharge Planning Form
  
• Tufts Medicare Preferred Hospital Discharge Summary Form (revised 11/2007) Word
  
• Tufts Medicare Preferred Hospital Discharge Summary Form Instructions (revised 11/2009) Word
• Tufts Medicare Preferred Home Safety Program Assessment Request
• Tufts Medicare Preferred SNF Review Form
• Universal Pharmacy Form

Notices & Letters

• DRG Provider Lack of Information-Denial of Payment Letter  Word
• Important Message from Medicare (IM) & Instructions
• Inpatient Delay Day-Denial of Payment Letter  Word
• New Member Welcome Letter  Word
• Noncompliance Letter  Word
  
• Notice of Financial Liability
• Notice of Medicare Non-Coverage (NOMNC) Word
• Notice of Medicare Non-Coverage (NOMNC) Form Instructions
  
• Per Diem Provider Lack of Information - Denial of Payment Letter  Word
  
• Referral/Authorization Waiver Requirement Physician Letter
• Referral Letter  Word
  
• Reinstatement Letter  Word
  

Documentation Tools

• Homecare & DME Authorization Log (Microsoft Word)