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Proposed Form Templates
Note:
These are proposed form templates for forms that were referenced in the binder Table of Contents but no PDF was provided. They are designed to be printable and match the style of existing forms.
Referral Form
Section 1: Demographics
Initial intake form for new referrals. Captures referral source, prospective member info, insurance, and reason for AFC services.
Client ID / Photo / SSN Page
Section 1: Demographics
Combined page for member photo, identification, SSN, and copies of ID cards and MassHealth card.
Insurance Verification Form
Section 1 & 2: Demographics / PA
Documents MassHealth eligibility verification, MCO enrollment, PCP info, and PA status tracking.
Medication List
Section 4: Medical
Annual medication list including prescriptions, OTC drugs, supplements. Includes allergy section and review history.
Caregiver Daily Log / Flowsheet
Section 7: Daily Logs
Weekly ADL/IADL tracking sheet with medication reminders, nutrition, vitals, and notes. Includes RN/CM review signature.
Caseworker Progress Notes
Section 11: Caseworker Notes
SOAP-format progress notes for Care Manager visits. Includes visit type, purpose checklist, member status, and follow-up.
Request for Medical Information
Section 12: Miscellaneous
Fax cover sheet for requesting medical records, face-to-face encounters, orders, and other info from PCP.
Official MassHealth Forms
These forms are available from Mass.gov:
PCP Order Form (PDF)
All MassHealth AFC Forms