Ma 97 form 2025

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The document is a guideline for completing the Outpatient Services Authorization Request form (MA 97) for the Commonwealth of Pennsylvania's Department of Public Welfare. It provides detailed instructions on how to fill out the form, including sections for patient and provider information, diagnosis codes, requested services, and necessary attachments. The form is used to request prior authorization or 1150 Waiver services for outpatient medical assistance programs.

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Click ‘Get Form’ to open the MA 97 in the editor.
Begin by checking the appropriate box for either Prior Authorization or 1150 Waiver in Items 1 & 2. Ensure only one box is checked per form.
Complete Patient Information (Items 3-6) using data from the Eligibility Verification System. Enter the recipient number, name, birthdate, and optionally check the sex.
Fill out Provider/Prescriber Information (Items 7-11) with details from your PROMISeTM Provider Enrollment Notice. Include provider name, ID, and any applicable reference numbers.
In Items 20A through 29, describe requested services and provide necessary codes and quantities. Be sure to include any additional information required for medical justification.
Finally, ensure that both the patient or authorized representative and practitioner sign and date the form in Items 33-36 before submitting it.

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