Forms

Here you'll find printable documents and forms available in PDF and/or text format. To download a free version of Adobe Reader, click on the icon at the bottom of this page.

Click on a section heading below for easy access to specific forms:
Administrative Forms
Ancillary Services Prospective Provider Inquiry Forms
Authorization Forms
Clinical Forms
Credentialing/Recredentialing Forms
Tufts Health Plan Medicare Preferred Forms
Tufts Health Plan Web Site Registration Forms

Administrative Forms

• Bone Density Equipment Information Form
• Practitioner Attestation Practice Site Standards Form
  
• Provider Information Change Form - Update your demographic information
• Provider Inquiry Line Automation Guide
  
• Provider Payment Dispute Cover Sheet
  
• Provider Payment Dispute Cover Sheet-CareLink CIGNA HealthCare as Primary Administrator
  
• Provider Payment Dispute Coversheet-CareLink Shared Administration
  
• Referral Waiver Form
  
• Request for Out of Plan ID Number Form
• Returned Funds Form
  
• Supply Order Form

Authorization Forms

• Anti-Obesity Authorization Form
• Continuous Glucose Monitoring System Prior Authorization Request Form
• Continuous Passive Motion Machine Form
  
• Guide for Completing Mental Health Care Service Requests Using IVR
  
• Heart Transplant Request for Coverage Form
• iCanChange® Authorization Form
  
• Infertility Authorization Form
• Infertility Treatment Summary Form
  
• Intestinal and Multivisceral Request for Coverage Form
  
• Kidney Transplant Request for Coverage Form
  
• Liver Transplant Request for Coverage Form
  
• Lung Transplant Request for Coverage Form
  
• Mental Health Provider Availability Form
  
• MHQP Obstetrical Risk Assessment Form
• Non-Emergency Ambulance Transportation: Ground Medical Necessity Form
  
• Occupational Therapy Authorization Form
• Orthognathic Surgery Authorization Form
  
• Pancreas Transplant Request for Coverage Form
  
• Preferred Drug List
  
• Physical Therapy Authorization Form
• Polysomnogram Sleep Study Form
• Preimplantation Genetic Determination Form
  
• Preregistration Form
  
• Psychological/Neuropsychological Testing
• Speech Therapy Evaluation and Authorization Form
  
• Stem Cell Transplant Authorization Form
• Tufts Health Plan Medicare Preferred Prescription Drug Plan Coverage Determination and Prior Authorization Request Form
  
• Uniformed Services Family Health Plan Occupational Therapy Completion Guide and Authorization Form
  
• Uniformed Services Family Health Plan Physical Therapy Program Guidelines and Authorization Form
• Universal Health Plan/Home Health Authorization Form (UHHA)
  
• Universal Pharmacy Form
• Upper GI Endoscopy Authorization Form
• Viscosupplement Authorization and Prescription Form
  

Clinical Forms

• Acute Inpatient Continued Stay Clinical Information Form
• Extended Care Inpatient Continued Stay Clinical Information Form - Additional
• Extended Care Inpatient Continued Stay Clinical Information Form - Initial
  

Credentialing Forms

• HealthCare Administrative Solutions (HCAS) Resources
  

Tufts Health Plan Web Site Registration Forms

• Provider Change Access Administrator Form
  
• Provider Registration Authorization Form
• Provider Unit Change Access Administrator Form
• Provider Unit Registration Authorization Form
  

Tufts Health Plan Medicare Preferred Forms
Organization Determinations, Notice & Letter Templates, Processes and Instructions

• Tufts Health Plan Medicare Preferred Organization Determination & Notice Instructions
  

Organization Determinations & Instructions

• Denial of Coverage & Expedited Approval Form (02/11/08) Word
  
• Denial of Coverage & Expedited Approval Form Instructions (10/01/05)
  
• Instructions for NOMNC (10/01/05)
• SNF/HHA/CORF Discharge Summary Form (02/11/08) Word
  
• SNF/HHA/CORF Discharge Summary Form Instructions Word
• Tufts Medicare Preferred Hospital Discharge Summary Form Word
  
• Tufts Medicare Preferred Hospital Discharge Summary Form Instructions Word
  

Notices & Letters

• DRG Provider Lack of Information-Denial of Payment Letter  Word
• Important Message from Medicare (IM) & Instructions
• Inpatient Delay Day-Denial of Payment Letter  Word
• Letter #1 Non-Compliance of Physician Treatment Plan (10/01/05)   Word
  
• Letter #2 Impaired Patient/Physician Relationship (10/01/05)  Word
• Medicare Advantage HMO Reinstatement of Services Letter (10/02/08)  Word
  
• Notice of Financial Liability (10/01/05)   Word
• Notice of Medicare Non-Coverage (NOMNC) (12/10/08)  Word
  
• Per Diem Provider Lack of Information - Denial of Payment Letter  Word
  
• Referral/Authorization Waiver Requirement Physician Letter
  

Processes & Workflows

• Post Stabilization Procedure(10/01/05)
  
• Stabilized Emergency Condition Preregistration Workflow(10/01/05)
  
• Notice of Medicare Non-Coverage-Homecare Workflow(10/01/05)
  
• Notice of Medicare Non-Coverage-SNF & TCU Workflow(10/01/05)
  
• SNF Concurrent Review Workflow-Post Notice of Medicare Non-Coverage(10/01/05)
  
• Independent Review Entity Appeal Workflow-Homecare(10/01/05)
  
• Independent Review Entity Appeal Workflow-SNF & TCU (10/01/05)
  
• Independent Review Entity Appeal Decision Key Contact Workflow (10/01/05)
  
• Key Contact Independent Review Entity MassPRO Workflow (10/01/05)
  

Documentation Tools

• Medical Record Review Summary (Microsoft Word)
  
• Homecare & DME Authorization Log (Microsoft Word)
  
• Institutional Log  (Microsoft Excel)
  
• Hospice & ESRD Log   (Microsoft Excel)

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