Forms and Applications

Provider Forms

• Patient Designation of Appeal (Grievance) Representative Form
• Pharmacy Forms
• Standardized Prior Authorization Request Form
• Provider Termination Request Form
• DME Prior Authorization Request Form
• MCO Combined Form for Enteral Products Authorization Requests
• Request for Claim Review Form
• Provider Audit Appeal Form
• PCP Site Change Form

Credentialing and Enrollment Forms

Neighborhood Health Plan, in conjunction with the Massachusetts Association of Health Plans, the Massachusetts Medical Society and the Massachusetts Hospital Association have developed a single, uniform credentialing application in order to streamline and facilitate the credentialing process for physicians practicing in the Commonwealth. Visit the Healthcare Administrative Solutions resource page for more information. If you have any questions, please contact NHP's Customer Care Center.

• HCAS Provider Enrollment Form - Contracted Providers Only