Provider Forms

Questions? Contact Provider Relations at 1-800-953-8854, then follow the prompts to the Provider Relations department or email ProviderRelations@mpcMedicaid.com.

For claims payment, MPC uses InstaMed to provide free Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). To register, call 1-866-945-7990 or visit instamed.com/eraeft.

Forms

Administrative Day Request Form/Log

Attachment C to Provider Agreement

Appeal Consent Form (PDF)

Cardiac Rehab Request Form

Enteral/Nutritional Supplement Form (PDF)

FDA Reporting Forms

Health Education Request Form

Joining Participating Provider Load Form

Local Health Services Form and Instructions (PDF)

Maryland Healthy Kids Program Pediatric Visit Sheets (Encounter Forms)

Maryland Healthy Kids/EPSDT Provider Application for Certification (PDF)

Maryland Healthy Kids Provider Forms

Maryland Uniform Consultation Referral Form (PDF)

Maryland Uniform Credentialing Form (PDF)

Medical Benefit Drug Prior Authorization Form (PDF)

Member Pre-Service Appeal Form (PDF)

New Prior-Authorization Form (PDF) – Required Form as of 4/1/21
Please refer to Pharmacy PA Forms for medication requests

Newborn Notification Form (PDF)

Nursing Facility Request Check List

Oncology Molecular Marker Testing Checklist

Pharmacy Prior Authorization Forms

NEW – Post Acute Clinical Record (PDF)

Post Acute Request Form (PDF)

Post-Service Appeal Form (PDF)

Prenatal Risk Assessment – Enriched Maternity Services Record

Primary Care Physician Change Form (PDF)

Provider Demographic Update form (PDF)

Remote Patient Monitoring (RPM) Preauthorization

Sterilization Consent Form (PDF)

Sterilization Consent Form – Spanish (PDF)

Transplant Eval Checklist – Final (PDF)

Transplant Listing Checklist – Final (PDF)

W-9 Form (PDF)