OMAP - Medical Assistance Forms



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Office of Medical Assistance Programs (OMAP)

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.
Questions about this should be referred to OMAPFormsRequest@state.pa.us

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.

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. See MA Bulletin # 99-95-06 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	ORDER (Quantity)
ENV-98	X-ray Envelope	25/pk	pk
ENV-320	Mailing Envelope	25/pk, 500/ctn	pk ctn
MA-3	Abortion Consent PRINTABLE	25/pk	pk
MA-3-S	Abortion Consent, Spanish PRINTABLE	25/pk	pk
MA-30	Hysterectomy Consent, English & Spanish PRINTABLE	25/pk	pk
MA-31	Sterilization Consent PRINTABLE	100/pk	pk
MA-31SP	Sterilization Consent, Spanish PRINTABLE	25/pk	pk
MA-51	Medical Evaluation – Plan of Care PRINTABLE	50/pk, 500/ctn	pk ctn
MA-61	Pharmacy Form – NDC	25/pk	pk
MA-79 (Skilled Nursing Care Assessment Form) This form is no longer available.
MA-91	Encounter Form PRINTABLE	25/pk	pk
MA-97	Outpatient Services Authorization Request PRINTABLE	25/pk	pk
MA-97C	Outpatient Services Authorization Request, Cont.	1000/ctn	ctn
MA-97LTC	Durable Medical Equipment (DME) Request for Nursing Facility Resident PRINTABLE	25/pk	pk
MA-98C (Dental Prior Authorization Request, Continuous, Pin-Fed.) This form is no longer available.
MA-103	Long Term Care Admission & Discharge Transmittal PRINTABLE	100/pk	pk
MA-112	Newborn Eligibility Form	25/pk	pk
MA-116	Hospital Transmittal/DRG Day Outlier Request PRINTABLE	50/pk	pk
MA-300D Series (Dental Services Invoice and Claim Adjustment) These claim forms are no longer available. Please refer to MA Bulletin 03-03-01 for further information.
MA-300X	Medical Assistance Provider Order Form	12/pk	pk
MA-301	Orthodontic Decision Checklist PRINTABLE	25/pk	pk
MA-302 Series (Drug Invoice and Claim Adjustment) These claim forms are no longer available.
MA-307	Signature Transmittal Form PRINTABLE	25/pk	pk
MA-309C (Long Term Care Invoice and Claim Adjustment) This claim form is no longer available.
MA-312	Home Health Services Authorization – Durable Med. Equipment PRINTABLE	25/pk	pk
MA-313C	Resource Computation Worksheet, Continuous, Pin-Fed PRINTABLE ONLY	1000/ctn
MA-314	Eligibility Determination Form	100/pk, 500/ctn	pk ctn
MA-319 Series (Medical Services Invoice and Claim Adjustment) All versions of this claim form are no longer available. Please refer to MA Bulletin 99-03-05 for further information.
MA-325	1150 Administrative Waiver Request PRINTABLE	50/pk	pk
MA-332	Presumptive Eligibility Application	100/pk	pk
MA-368	Recipient Statement PRINTABLE	25/pk	pk
MA-368-S	Recipient Statement, Spanish PRINTABLE	25/pk	pk
MA-369	Recipient Statement (Incest Under Age 18) PRINTABLE	25/pk	pk
MA-369S	Recipient Statement (Incest under Age 18), Spanish PRINTABLE	25/pk	pk
MA-372	Certification of Terminal Illness PRINTABLE	25/pk, 500/ctn	pk ctn
MA-373	Election of Hospice Care	25/pk, 500/ctn	pk ctn
MA-374	Change of Hospice Provider	25/pk, 500/ctn	pk ctn
MA-375	Revocation of Hospice Care	50/pk, 500/ctn	pk ctn
MA-376 Effective March 1st, 2009	Preadmission Screening Resident Review (PASRR) Identification Form PRINTABLE	25/pk	pk
MA-376.2	Preadmission Screening Instrument PRINTABLE	25/pk	pk
MA-399	Service Coordination Plan PRINTABLE	25/pk, 500/ctn	pk ctn
MA-400	Case Management Activity Log PRINTABLE	50/pk, 500/ctn	pk ctn
MA-401	Admissions Notice Packet (Nursing Homes) PRINTABLE	100/ctn	ctn
MA-401S	Admissions Notice Pk. (Nursing Homes), Spanish PRINTABLE	25/pk	pk
MA-402	Healthy Beginnings Plus Letter of Agreement PRINTABLE	100/pk	pk
MA-403	Healthy Beginnings Plus Care Coordination Package PRINTABLE	25/pk	pk
MA-408	Target Resident Reporting Form PRINTABLE	25/pk	pk
MA-464	EVS Response Worksheet PRINTABLE	100/pk	pk
MA-466	Deluxe Frames	25/pk	pk
MA-467	Temporary Newborn Eligibility Authorization	50/pk	pk
MA-517 (PA Children's Checkup [EPSDT]) This form is no longer available. Please refer to MA Bulletin 01-03-08 for further information.
MA-531	Supplemental Attachment for Renal Dialysis Providers PRINTABLE	100/pk	pk
MA-538	CMS-1500 Commercial Insurance Attachment PRINTABLE	50/pk, 500/ctn	pk ctn
MA-539	CMS-1500 Medicare Attachment PRINTABLE	50/pk, 500/ctn	pk ctn
MA-791C	State Match Verification, Continuous, Pin-Fed PRINTABLE	1000/ctn	ctn
PA-4	Authorization for Release of Information PRINTABLE	100/pk, 500/ctn	pk ctn
PA-600CH	Application for Health Care Coverage	50/pk, 400/ctn	pk ctn
PA-600CH-S	Application for Health Care Coverage - Spanish Version	50/pk, 400/ctn	pk ctn
PA-600L	MA (Medicaid) Financial Eligibility Application PRINTABLE	100/pk	pk
PA-600M	Mail-in Application for Payment of Medicare Part B	50/pk	pk
PA-600P	Application for Benefits	100/pk	pk
PA-600WP	Application for Services in Your Home PRINTABLE	50/pk	pk
PA-1572	Resource Assessment	50/pk	pk
PA-1572S	Resource Assessment, Spanish	25/pk	pk
PA-1615	Outstationing Verification Checklist PRINTABLE	100/pk	pk
PA-1616	Outstationing Provider Checklist PRINTABLE	100/pk	pk
PA-1663	Employability Assessment Form PRINTABLE	100/pk	pk
PA-1663S	Employability Assessment Form, Spanish Version PRINTABLE	100/pk	pk
PA-1666	GA Criminal History Inquiry, English & Spanish PRINTABLE	100/pk	pk
PA-1671 (SG)	Health Sustaining Medication Assessment Form PRINTABLE	100/pk	pk
PA-1809	Citizenship and Identity Information	50/pk	pk
PA-1809S	Citizenship and Identity Information, Spanish	50/pk	pk
PA-1817	Affidavit Attesting to Unavailability of Documentary Evidence of Citizenship	50/pk	pk
PA-1817S	Affidavit Attesting to Unavailability of Documentary Evidence of Citizenship, Spanish	50/pk	pk
PA-1818	Affidavit Attesting to Citizenship	50/pk	pk
PA-1818S	Affidavit Attesting to Citizenship, Spanish	50/pk	pk
PA-1819	Affidavit Attesting to Identity of Minor Child	50/pk	pk
PA-1819S	Affidavit Attesting to Identity of Minor Child, Spanish	50/pk	pk
PUB-159	Protecting Your Spouse's Resources	50/pk	pk
PUB-332	Medical Assistance Estate Recovery Program PRINTABLE	50/pk	pk
PUB-332S	Medical Assistance Estate Recovery Program - Spanish Version PRINTABLE	25/pk	pk
PUB-473 - Revised to include information from PUB 473 & PUB 474.	Healthy Beginnings Plus, Brochure PRINTABLE	50/pk	pk
PUB-473S - TEMPORARILY UNAVAILABLE � UPDATING	Healthy Beginnings Plus, Brochure - Spanish	50/pk	pk
PUB-474 -This is no longer available. Please refer to the revised PUB 473.	Healthy Beginnings Plus, Fee-for-Service	50/pk	pk
PUB-474S - This is no longer available. Please refer to the revised PUB 473S.	Healthy Beginnings Plus, Fee-for-Service - Spanish	50/pk	pk
SS-5	Application for Social Security Card	100/pk, 1800/ctn	pk ctn
Click 'Order Forms' to begin processing your request (a valid address will be required):

Internet MA 300X 06/03

Other Downloadable Forms

Last Modified: 02/05/2010

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