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  • October 1, 2013 - September 30, 2014

    Order Medical Assistance Forms

    ONLY PROMISe PROVIDERS MAY ORDER AND RECEIVE MA PROVIDER FORMS.
    You MUST have an MA Provider ID number to order from this system.
    All others may download the printable versions as needed.
    Any form that is ‘Printable Only’ cannot be ordered in bulk by anyone.
    Questions about this should be referred to OMAPFormsRequest@pa.gov


    Forms Available to Order


    The Office of Medical Assistance Programs (OMAP) produces and distributes over 70 forms and envelopes for provider use at no charge to the provider. There may be a limit to how many forms can be ordered at one time. A department representative will contact you if your order exceeds any limits.

    Because many of these forms are handled electronically upon receipt by the Department, in most cases only the original forms printed by a qualified printing contractor will be accepted. Only forms identified as "PRINTABLE" in the table below may be printed from this website and used. All other forms in this section of the website are for viewing purposes only and must be ordered from our printing contractor. Forms labeled as ‘Printable Only’ are not available for bulk ordering. See MA Bulletin # 99-12-02 for instructions on how to use the MA 300X to order forms or you may use this page to order forms via the internet.

    The table below lists the various MA forms and envelopes available to providers. To view a particular form, click on the form number or title in the table below. To order forms, indicate quantity desired in the box to the right of each form line. Then click on the "Order Forms" button at the bottom of this page.

    These forms are in Adobe PDF format and you must have a copy of Adobe Acrobat Reader installed on your system to view them.

    Form # Title Package
    pk = packet
    ctn = carton
    Quantity
    ENV-K-98 X-ray Envelope
    Download
    25/pk
    ENV-K-320 Mailing Envelope
    Download
    25/pk
    500/ctn
    MA 3 Abortion Consent
    (Printable Only) Download
       
    MA 3-S Abortion Consent, Spanish
    (Printable Only) Download
       
    MA 30 Hysterectomy Consent, English & Spanish
    (Printable Only) Download
       
    MA 31 Sterilization Consent
    (Printable Only) Download
       
    MA 31-S Sterilization Consent, Spanish
    (Printable Only) Download
       
    MA 51 Medical Evaluation – Plan of Care
    (Printable Only) Download
       
    MA 61 Pharmacy Form – NDC
    Download
    25/pk
    MA 91 Encounter Form
    (Printable Only) Download
       
    MA 97 Outpatient Services Authorization Request
    (Printable) Download
    25/pk
    MA 97C Outpatient Services Authorization Request, Continous Pin-Fed form
    Download
    1000/ctn
    MA 97LTC Durable Medical Equipment (DME) Request for Nursing Facility Resident
    (Printable Only) Download
       
    MA 103 Long Term Care Admission & Discharge Transmittal
    (Printable) Download
    100/pk
    MA 112 Newborn Eligibility Form
    (Printable Only) Download
       
    MA 116 Hospital Transmittal/DRG Day Outlier Request
    (Printable Only) Download
       
    MA 300X Medical Assistance Provider Order Form
    Download
    12/pk
    MA 301 Orthodontic Decision Checklist
    (Printable Only) Download
       
    MA 307 Signature Transmittal Form
    (Printable) Download
    25/pk
    MA 312 Home Health Services Authorization – Durable Med. Equipment
    (Printable) Download
    25/pk
    MA 314 Eligibility Determination Form
    Download
    100/pk
    500/ctn
    MA 325 1150 Administrative Waiver Request
    (Printable) Download
    50/pk
    MA 332 Presumptive Eligibility Application
    Download
    100/pk
    MA 341 Recipient Statement
    (Printable Only) Download
       
    MA 368 Recipient Statement
    (Printable Only) Download
       
    MA 368-S Recipient Statement, Spanish
    (Printable Only) Download
       
    MA 369 Recipient Statement (Incest Under Age 18)
    (Printable Only) Download
       
    MA 369-S Recipient Statement (Incest under Age 18), Spanish
    (Printable Only) Download
       
    MA 372 Certification of Terminal Illness
    (Printable Only) Download
       
    MA 373 Recipient Statement Form
    (Printable) Download
    25/pk
       
    MA 373-S Recipient Statement, Spanish Form
    (Printable) Download
    25/pk
       
    MA 374 Change of Hospice Provider
    Download
    25/pk
    500/ctn
    MA 375 Revocation of Hospice Care
    Download
    50/pk
    500/ctn
    MA 376 Preadmission Screening Resident Review (PASRR) Identification Form
    (Printable) Download
    25/pk
    MA 376.2 Preadmission Screening Instrument
    (Printable) Download
    25/pk
    MA 399 Service Coordination Plan
    (Printable) Download
    25/pk
    500/ctn
    MA 400 Case Management Activity Log
    (Printable) Download
    50/pk
    500/ctn
    MA 401 Admissions Notice Packet (Nursing Homes)
    (Printable) Download
    100/ctn
    MA 401-S Admissions Notice Pk. (Nursing Homes), Spanish
    (Printable) Download
    25/pk
    MA 402 Healthy Beginnings Plus Letter of Agreement
    (Printable) Download
    100/pk
    MA 403 Healthy Beginnings Plus Care Coordination Package
    (Printable) Download
    25/pk
    MA 408 Target Resident Reporting Form
    (Printable) Download
    25/pk
    MA 464 EVS Response Worksheet
    (Printable Only) Download
       
    MA 466 Deluxe Frames
    (Printable Only) Download
       
    MA 467 Temporary Newborn Eligibility Authorization
    Download
    50/pk
    MA 531 Supplemental Attachment for Renal Dialysis Providers
    (Printable) Download
    100/pk
    MA 538 CMS-1500 Commercial Insurance Attachment
    (Printable) Download
    50/pk
    500/ctn
    MA 539 CMS-1500 Medicare Attachment
    (Printable) Download
    50/pk
    MA 549 Dental Benefit Limit Exception Request Form
    (Printable) Download
    100/pk
    MA 551 OPPC Self-Reporting Form
    (Printable Only) Download
       
    MA 552 Obstetrical Needs Assessment
    (Printable Only) Download
       
    MA 791 C State Match Verification, Continuous, Pin-Fed
    Download
    1000/ctn
    PA 4 Authorization for Release of Information
    (Printable Only) Download
       
    PA 600 HC Application for Health Care Coverage
    (Printable) Download
    50/pk
    PA 600 HC-S Application for Health Care Coverage, Spanish
    (Printable) Download
    50/pk
    PA 600 L (SG) MA (Medicaid) Financial Eligibility Application
    (Printable) Download
    100/pk
    PA 600 M (SG) Mail-in Application for Payment of Medicare Part B
    Download
    50/pk
    PA 600 P Application for Benefits
    (Printable) Download
    100/pk
    PA 600-S Application for Benefits, Spanish
    (Printable) Download
    50/pk
    PA 600 WP Application for Services in Your Home
    (Printable)
    50/pk
    PA 1572 Resource Assessment
    Download
    50/pk
    PA 1572-S Resource Assessment, Spanish
    Download
    25/pk
    PA 1615 Outstationing Verification Checklist
    (Printable Only) Download
       
    PA 1616 Outstationing Provider Checklist
    (Printable Only) Download
       
    PA 1663 Employability Assessment Form
    (Printable Only) Download
       
    PA 1666 SG GA Criminal History Inquiry
    (Printable Only) Download
       
    PA 1666-S SG GA Criminal History Inquiry, Spanish
    (Printable Only) Download
       
    PA 1671 (SG) Health Sustaining Medication Assessment Form
    (Printable Only) Download
       
    PA 1809 (SG) Citizenship and Identity Information
    (Printable Only) Download
       
    PA 1809-S (SG) Citizenship and Identity Information, Spanish
    (Printable Only) Download
       
    PA 1817 Affidavit Attesting to Unavailability of Documentary Evidence of Citizenship
    (Printable Only) Download
       
    PA 1817-S Affidavit Attesting to Unavailability of Documentary Evidence of Citizenship, Spanish
    (Printable Only) Download
       
    PA 1818 Affidavit Attesting to Citizenship
    (Printable Only) Download
       
    PA 1818-S Affidavit Attesting to Citizenship, Spanish
    (Printable Only) Download
       
    PA 1819 Affidavit Attesting to Identity of Minor Child
    (Printable Only) Download
       
    PA 1819-S Affidavit Attesting to Identity of Minor Child, Spanish
    (Printable Only) Download
       
    PUB 159 Protecting Your Spouse's Resources
    Download
    50/pk
    PUB 332 Estate Recovery Program
    (Printable) Download
    50/pk
    PUB 332-S Estate Recovery Program, Spanish
    (Printable) Download
    50/pk
    PUB 473 Healthy Beginnings Plus FAQ Brochure
    (Printable) Download
    50/pk
    PUB 473-S Healthy Beginnings Plus FAQ Brochure, Spanish
    (Printable) Download
    50/pk
    SS 5 Application for Social Security Card
    (Printable Only) Download