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Provider forms and references

 

Forms for Medical Assistance members are available from the Pennsylvania Department of Human Services website. Most forms are available in both English and Spanish. Available forms include:

  • Abortion Consent 
  • Eligibility Determination
  • Hysterectomy Consent 
  • Medical Assistance Provider Order 
  • Medical Evaluation Plan of Care 
  • Newborn Eligibility 
  • Obstetrical Needs Assessment
  • Outpatient Services Authorization Request 
  • Recipient Statement
  • Service Coordination Plan
  • Sterilization Consent