Provider Manual and Forms

Provider Manual and Forms

• Download the Keystone First – CHIP provider manual (PDF)

Forms

• DHS MA-112 newborn form (PDF)
• Physician certification for abortion (PDF)
• Recipient statement form under age 18 (PDF)
• Patient consent form for physicians filing a grievance on behalf of an Enrollee (PDF)
• Claims project submission form (XLS)
• Prior authorization form (PDF)
• Pregnant patients dental form (PDF)
• Provider change form (PDF)
• Provider claim refund form (PDF)
• Hospital notification of emergency admission form (PDF)