If you are enrolled in Medicaid, you must renew once a year or you will lose your coverage.

Renew Now

Provider Forms

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

Appeal Consent Form (PDF)

Enteral/Nutritional Supplement Form (PDF)

FDA Reporting Forms

Health Education Presentations

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)

Pharmacy Prior Authorization Forms

Post-Service Appeal Form (PDF)

Primary Care Physician Change Form (PDF)

Provider Verification 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)

Know The Facts About Coronavirus (COVID-19)

Symptoms are flu-like, including: fever, coughing, and shortness of breath.

If you think you might have been exposed, contact your doctor immediately. You can also have a video visit with a doctor using the MyVirtualMPC app.

It is important to do everything you can to protect yourself from COVID-19.

Important Claims Processing Update

Effective 6/14/2021, all paper claims regardless of DOS should be sent to:
Maryland Physicians Care
P.O. Box 21099
Eagan, MN 55121