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Home > Welcome Providers > Provider Manual and Forms

Provider Manual and Forms

Providers, use the forms below to work with Keystone First Community HealthChoices.

  • Download the provider manual (PDF)
  • 2025 provider manual updates (PDF)

Forms

  • Claims project submission form (XLS)
  • DHS MA-112 newborn form (PDF)
  • Diaper and incontinence supply prescription form (PDF)
  • Enrollee consent form for physicians filing a grievance on behalf of a participant (PDF)
  • Formulary addition/deletion/modification request form (PDF)
  • Hospital notification of emergent admissions (PDF)
  • Hysterectomy consent form (PDF)
  • LTSS provider change form (PDF)
  • Obstetrical needs assessment form (ONAF) (PDF)
  • Pharmacy forms
  • Physician certification for abortion (PDF)
  • Prior authorization form (PDF)
  • Provider change form (PDF)
  • Provider claim refund form (PDF)
  • Recipient statement form (PDF)
  • Sterilization consent form (PDF)
  • Time sheet documentation for manual EVV entries/edits (PDF)
Providers
  • Join our network
  • Prior authorization lookup tool
  • Find a doctor, drug, or pharmacy
  • Provider manual and forms
  • Pharmacy services
  • Claims and billing
  • Training
  • Resources
  • Sign up for email alerts
Keystone First Community HealthChoices
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Coverage by Vista Health Plan, an independent licensee of the Blue Cross and Blue Shield Association.

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