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 Form (PDF)

Appeal Consent Form (PDF)

Enteral/Nutritional Supplement Form

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)

New Prior-Authorization Form (PDF) – Required Form as of 4/1/21

Newborn Notification Form (PDF)

Pharmacy Prior Authorization Forms

Primary Care Physician Change Form (PDF)

Provider Verification Form (PDF)

Remote Patient Monitoring (RPM) Preauthorization

Sterilization Consent Form (PDF)

Sterilization Consent Form – Spanish (PDF)

W-9 Form (PDF)