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If you have any questions regarding the information in CCA’s provider manual, please email Provider Relations at [email protected].

Section 18: Forms

Forms

Appointment of Representative (Form CMS-1696)*

Download:

EDI Transactions Questionnaire Form

Download:

Notice of Privacy Practices

Download:

Standardized Prior Authorization Request Form – Mass Collaborative

Download:

Prior Authorization Form – Cardiac Imaging

Download:

Prior Authorization Form – CT/CTA/MRI/MRA

Download:

Prior Authorization Form – PET – PET CT

Download:

PA Form – Massachusetts Medication Requests

Download:

Prior Authorization Form – Repetitive Transcranial Magnetic Stimulation Request

Download:

Prior Authorization Form – Psychological and Neuropsychological Assessment

Download:

Provider Referral Form: SCO

Download:

Provider Referral Form: One Care

Download:

The Patient Health Questionnaire 2 Overview (PHQ 2)

Download:

The Patient Health Questionnaire (PHQ 9)

Download:

Mental Status Exam

Download:

CAGE Questionnaire

Download:

Form Instructions

Claims Requirements 1500 Professional Form

Download:

Claims Requirements UB Institutional Form

Download: