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MetroPlusHealth actively maintains a library of resources and forms to assist our participating providers treat their patients.
ABA Universal Request Form
Children’s HCBS Authorization Request Form
CORE Provider Service Initiation Notification Form
Home Care Services Request Form
Managed Long Term Care (MLTC)
General Essential Plan, MarketPlace Plans, SHOP Plans, Gold/GoldCare Plans
Medication Prior Authorization Form
Medicare Coverage Determination Request Form
General Medical Authorization Form
(exclusion may apply to some plans)
Medicare Redetermination Request Form
Outpatient Therapy Request Form
Physician Administered or Infusion Drug Form
Specialty Medication Prior Authorization Form
Growth Hormone Prior Authorization Request Form
Hepatitis C Prior Authorization Request Form
Provider DME Authorization List
Informed Consent for Hysterectomy and Sterilization
Acknowledgement of Hysterectomy – LDSS-3113
Sterilization Consent Form – LDSS-3134
Pay for Performance Brochure
Care for Older Adults Assessment Form
Electronic Visit Verification Form
EFT Enrollment Form
Toolkit / Resources:
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