Forms that make doing business with us easier
Whether you need to make a referral, request prior authorization for a treatment or more, filling out the necessary forms will help us respond to your needs quickly and efficiently. Just click on the appropriate form name below to get started. Please contact Provider Relations at 1-800-953-8854 (option 4), then follow the prompts to the Provider Relations department, or email MPCproviders@marylandphysicianscare.com with any questions.
Enroll electronically with PaySpan by visiting My MPC Source, our Secure Web Portal. For assistance registering please call PaySpan's Provider Support at 877-331-7154. option 1, Monday through Friday, 8:00 am to 8:00 pm ET or email at firstname.lastname@example.org.
General Provider Forms
- Appeal/Reconsideration Form (PDF)
- FDA Reporting Forms
- Primary Care Physician Change Form (PDF)
- Maryland Uniform Consultation Referral Form (PDF)
- Maryland Uniform Credentialing Form (PDF)
- W-9 Form (PDF)
- Maryland Healthy Kids/EPSDT Provider Application for Certification (PDF)
- Provider Verification Form (PDF)
- Pharmacy Prior Authorization Forms
- Maryland Healthy Kids Provider Forms
- Maryland Healthy Kids Program Pediatric Visit Sheets (Encounter Forms)
- Health Education Presentations
- Inpatient Prior Authorization (PDF)
- Outpatient Prior Authorization (PDF)
- Remote Patient Monitoring (RPM) Preauthorization
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