Provider Manual and Forms

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

• Download the provider manual (PDF)
• 2024 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)