| Link |
Description |
| Form 282A |
Form 282A /Medicaid Hospice Care Notification Form |
| Form 282B |
Form 282B /Service Utilization within Hospice by Recipient |
| Form 272REV |
Form 272REV /Incontinence Products Prior Authorization Revision Request Form |
| Form 286 |
Form 286 /Request for Incontinence Product Not on Product Offering Sheet |
| Form 272 DIA |
Form 272 DIA /Incontinence Products Prior Authorization Request Form |
| Form 904 |
Form 904 /Certification of the Decision to Terminate Pregnancy |
| Document 904(i) |
Instructions for Form 904 |
| Form 910 |
Form 910 /Acknowledgment of Sterilization As a Result of Hysterectomy |
| Form 910 (Spanish) |
Formulario de 910 /Notificación de Esterilización Como Resultado de Una Histerectomía |
| Adjustment Form |
Adjustment/Recoupment Request |
| ALS form |
Advanced Life Support for Ambulance Certification Form. |
| Appendix B |
Standard Trading Partners Agreement Form. |
| BLS Form |
Basic Life Support for Ambulance Certification Form. |
| Crossover Form |
NH Medicaid Medicare Crossover Form |
| EDI Registration |
EDI Registration Form. |
| Dental Instructions |
ADA Dental Claim Form Completion Instructions |
| DME Form |
09/22/2008
Durable Medical Equipment Prior Authorization Request Form (272D) |
| Excess Service |
09/14/2007
Request for Prior Authorization in Excess of Service Limits (272E) |
| Medical Evaluation Request |
09/14/2007
Medical Evaluation Request (non-wheelchair) (272EQ) |
| Excess Service Psychotherapy |
09/22/2008
Request for Prior Authorization in Excess of Service Limits - Psychotherapy (272EP) |
| Gastric Bypass Surgery |
10/10/2007
273GB Gastric Bypass Surgery Prior Authorization Request (273GB) |
| Panniculectomy |
09/14/2007
273PY Panniculectomy Prior Authorization Request (273PY) |
| Pregnancy Notification |
Updated 02/01/2008
273PG Pregnancy Notification (273PG) |
| Reduction Mammaplasty |
09/14/2007
273MM Reduction Mammaplasty (273MM) |
| CMS 1500 Completion Instructions |
CMS/0805 1500 Complete Instructions |
| Hospital Form |
In-Patient Hospitalization - Out of State Prior Authorization Request Form
(272H) |
| Mobility Evaluation Form |
09/14/2007
Mobility Evaluation Form (272M) |
| Diagnostic Imaging |
2/11/2009
Request For Prior Authorization For Diagnostic Imaging (272X) |
| Nursing Home |
UB04 Completion Instructions for Nursing Homes Only |
| Override Request Form |
NH DHHS Form #957x - Override Request Form |
| PE Form |
NH Provider Change Request Form |
| Provider Application |
Provider Application for Enrollment in the New Hampshire Title XIX (Medicaid)
Program.
Special Note:
This form cannot be emailed or faxed in. Original signatures are necessary.
The form must be mailed to HP for processing. |
| Psychotherapy over limit |
Prior Authorization of psychotherapy services in excess of service limits
application. |
Consent English
Consent Spanish |
112 - Sterilization Consent Form. (English)
112 - Sterilization Consent Form. (Spanish) |
| Swing Bed Providers |
UB04 Completion Instructions for Swing Bed Providers Only |
| UB04 Hospital |
UB04 Paper Completion Instructions for Hospitals Only |
| Wheelchair Van |
Documentation to Support Use of Wheelchair Van Services (975) |
| Dental Billing |
837 - Dental Billing Requirements |
| Nursing Home |
837 - Nursing Home Requirements |
| OP Billing |
837 - OP Billing Requirements |
| Professional Billing |
837 - Professional Billing Requirements |
| Swing Billing |
837 - Swing Billing Requirements |
| IP Billing |
837 - IP Billing Requirements |
| Form 911 |
911 - Acknowledgement of sterilization resulting from hysterectomy. |
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