Medicaid Provider Forms

The Office of Medical Assistance Programs (OMAP) produces and distributes over 70 forms and envelopes for use at no charge to Medicaid providers. There may be a limit to how many forms can be ordered at one time.

Who can order forms?

Only PROMISeTM providers may order and receive Medicaid provider forms. You must have an MA Provider ID number to order from this system.

  • All others may download the printable versions as needed.
  • Any form that is ‘Printable Only’ cannot be ordered in bulk by anyone.
  • Questions about this should be referred to OMAPFormsRequest@pa.gov

Forms Available to Order

Because many of these forms are handled electronically upon receipt by the department, in most cases only the original forms printed by a qualified printing contractor will be accepted. 

Only forms identified as "PRINTABLE" in the table below may be printed from this website and used. 

All other forms in this section of the website are for viewing purposes only and must be ordered from our printing contractor. Forms labeled as "Printable Only" are not available for bulk ordering. See MA Bulletin # 99-12-02 for instructions on how to use the MA 300X to order forms or you may use this page to order forms via the internet.

Printable Forms

The table lists the various MA forms and envelopes available to providers. To view a particular form, click on VIEW PDF the table below. To order forms, complete the form at the bottom of this page.

These forms are in Adobe PDF format and you must have a copy of Adobe Acrobat Reader installed on your system to view them.

NOTE: (*) This form is not available for ordering. If you are unable to access the downloadable version of the form online, you may request a copy by calling the correct number for your provider type. Provider Service Center: 1-800-537-8862; Office of Mental Health and Substance Abuse Services (OMHSAS): 1-800-433-4459; Office of Long Term Living (OLTL): 1-800-932-0939; Office of Developmental Programs (ODP): 1-888-565-9435.

 

Form #

Title

Unit Package

PDF

ENV-K-98

X Ray Envelope

25/pk

View PDF

ENV-K-320

Mailing Envelope

25/pk, 500/ctn

View PDF

MA 3

Abortion Consent

*See above. This form is not available for ordering.

View PDF

MA 3-S

Abortion Consent, Spanish

*See above. This form is not available for ordering.

View PDF

MA 30

Hysterectomy Consent, English & Spanish

*See above. This form is not available for ordering.

View PDF

MA 31

Sterilization Consent

*See above. This form is not available for ordering.

View PDF

MA 31-S

Sterilization Consent, Spanish

*See above. This form is not available for ordering.

View PDF

MA 51

Medical Evaluation – Plan of Care

*See above. This form is not available for ordering.

View PDF

MA 91

Encounter Form

*See above. This form is not available for ordering.

View PDF

MA 97

Outpatient Services Auth Request

25/pk

View PDF

MA 97LTC

Durable Medical Equipment (DME) Request for Nursing Facility Resident

*See above. This form is not available for ordering.

View PDF

MA 98

Dental Prior Auth Request

25/pk

View PDF

MA 112

Newborn Eligibility Form

*See above. This form is not available for ordering.

View PDF

MA 116

Hospital Transmittal/DRG Day Outlier Request

*See above. This form is not available for ordering.

View PDF

MA 300-X

Medical Assistance Provider Order Form

12/pk

View PDF

MA 301

Orthodontic Decision Checklist

*See above. This form is not available for ordering.

View PDF

MA 307

Signature Trasmittal Form

25/pk

View PDF

MA 312

Home Health Services Authorization – Durable Med. Equipment

*See above. This form is not available for ordering.

View PDF

MA 314

Eligibility Determination Form

100/pk, 500/ctn

View PDF

MA 325

1150 Administrative Waiver Request

50/pk

View PDF

MA 332

Presumptive Eligibility Application

*See above. This form is not available for ordering.

View PDF

MA 341

Recipient Statement

*See above. This form is not available for ordering.

View PDF

MA 368

Recipient Statement under 18

*See above. This form is not available for ordering.

View PDF

MA 368-S

Recipient Statement under 18, Spanish

*See above. This form is not available for ordering.

View PDF

MA 369

Recipient Statement (Incest Under Age 18)

*See above. This form is not available for ordering.

View PDF

MA 369-S

Recipient Statement (Incest under Age 18), Spanish

*See above. This form is not available for ordering.

View PDF

MA 372

Certification of Terminal Illness

*See above. This form is not available for ordering.

View PDF

MA 373

Election of Hospice Care

25/pk

View PDF

MA 373-S

Choice of Pallative Care Spanish

25/pk

View PDF

MA 374

Change of Hospice Provider

25/pk, 500/ctn

View PDF

MA 375

Revocation of Hospice Care

50/pk, 500/ctn

View PDF

MA 376

Preadmission Screening Resident Review PASRR Level I Form

*See above. This form is not available for ordering.

View PDF

MA 376.2

Preadmission Screening Resident Review PASRR Level II Form

*See above. This form is not available for ordering.

View PDF

MA 400

Case Management Activity Log

50/pk, 500/ctn

View PDF

MA 401

Admissions Notice Packet (Nursing Homes)

100/ctn

View PDF

MA 401-S

Admissions Notice Pk. (Nursing Homes), Spanish

25/pk

View PDF

MA 402

Healthy Beginnings Plus Letter of Agreement

100/pk

View PDF

MA 403

Healthy Beginnings Plus Care Coordination Package

25/pk

View PDF

MA 408

Target Resident Reporting Form.pdf

25/pk

View PDF

MA 464

EVS Response Worksheet

*See above. This form is not available for ordering.

View PDF

MA 466

Deluxe Frames

*See above. This form is not available for ordering.

View PDF

MA 467

Temporary Newborn Eligibility Authorization

50/pk

View PDF

MA 531

Supplemental Attachment for Renal Dialysis Providers

*See above. This form is not available for ordering.

View PDF

MA 538

CMS-1500 Commerical Insurance Act

50/pk, 500/ctn

View PDF

MA 539

CMS-1500 Medicare Attachment

50/pk

View PDF

MA 549

Dental Benefit Limit Exception Request Form

100/pk

View PDF

MA 551

OPPC Self-Reporting Form

*See above. This form is not available for ordering.

View PDF

MA 552

Obstetrical Needs Assessment

*See above. This form is not available for ordering.

View PDF

MA 570

Physicians Certification Form (Revised)

 

View PDF

MA 791

State Match Verification

*See above. This form is not available for ordering.

View PDF

PA 4

Authorization for Release of Information

*See above. This form is not available for ordering.

View PDF

PA 4-S

Authorization for Release of Information, Spanish

*See above. This form is not available for ordering.

View PDF

PA 600 B

Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program Medicaid Eligibility Application

*See above. This form is not available for ordering.

View PDF

PA 600 B-S

Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program Medicaid Eligibility Application, Spanish

*See above. This form is not available for ordering.

View PDF

PA 600 BR

Breast and Cervical Cancer Prevention and Treatment (BCCPT)Program – Renewal

*See above. This form is not available for ordering.

View PDF

PA 600 BR-S

Breast and Cervical Cancer Prevention and Treatment (BCCPT)Program – Renewal, Spanish

*See above. This form is not available for ordering.

View PDF

PA 600 HC

Application for Health Care Coverage

50/pk

View PDF

PA 600 HC-S

Application for Health Care Coverage, Spanish

50/pk

View PDF

PA 600 L (AS)

Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services

100/pk

View PDF

PA 600 M (AS)

Mail-in Application for Payment of Medicare Part B

50/pk

View PDF

PA 600 P

Application for Benefits

100/pk

View PDF

PA 600 P-S

Application for Benefits Spanish

50/pk

View PDF

PA 1572

Resource Assessment

50/pk

View PDF

PA 1572-S

Resource Assessment Spanish

50/pk

View PDF

PA 1615

Outstationing Verification Checklist

*See above. This form is not available for ordering.

View PDF

PA 1616

Outstationing Provider Checklist

*See above. This form is not available for ordering.

View PDF

PA 1663

Employability Assessment Form

*See above. This form is not available for ordering.

View PDF

PA 1666 SG

GA Criminal History Inquiry

*See above. This form is not available for ordering.

View PDF

PA 1666-S SG

GA Criminal History Inquiry, Spanish

*See above. This form is not available for ordering.

View PDF

PA 1671 (SG)

Health Sustaining Medication Assessment Form

*See above. This form is not available for ordering.

View PDF

PA 1809 (SG)

Citizenship and Identity Information

*See above. This form is not available for ordering.

View PDF

PA 1809-S (SG)

Citizenship and Identity Information, Spanish

*See above. This form is not available for ordering.

View PDF

PA 1817

Affidavit Attesting to Unavailability of Documentary Evidence of Citizenship

*See above. This form is not available for ordering.

View PDF

PA 1817-S

Affidavit Attesting to Unavailability of Documentary Evidence of Citizenship, Spanish

*See above. This form is not available for ordering.

View PDF

PA 1818

Affidavit Attesting to Citizenship

*See above. This form is not available for ordering.

View PDF

PA 1818-S

Affidavit Attesting to Citizenship, Spanish

*See above. This form is not available for ordering.

View PDF

PA 1819 (SG)

Affidavit Attesting to Identity of Minor Child

*See above. This form is not available for ordering.

View PDF

PA 1819-S (SG)

Affidavit Attesting to Identity of Minor Child, Spanish

*See above. This form is not available for ordering.

View PDF

PUB 159

Protecting Your Spouse's Resources

50/pk

View PDF

PUB 332

Estate Recovery Program

50/pk

View PDF

PUB 332-S

Estate Recovery Program, Spanish

50/pk

View PDF

PUB 473

Healthy Beginnings Plus FAQ Brochure

50/pk

View PDF

PUB 473-S

Healthy Beginnings Plus FAQ Brochure, Spanish

50/pk

View PDF

SS 5

Application for Social Security Card

*See above. This form is not available for ordering.

View PDF