Pt1 form online 2026

1. Click ‘Get Form’ to open the pt1 form in the editor.
2. In Section 1, enter the MassHealth member's last name, first name, date of birth, member ID, and telephone number. Provide the home address and any alternate pick-up address if applicable.
3. Proceed to Section 2 and fill in the provider's name, telephone number, address, MassHealth provider ID/service location, and NPI. Ensure that the provider is an active MassHealth participant.
4. In Section 3, indicate if the treating provider is the same as listed in Section 2 by checking the appropriate box. If different, provide their details.
5. Describe the medical treatment type in Section 4 and specify how long and how frequently transportation will be needed in Section 5.
6. In Section 6, explain any medical reasons preventing public transportation use. Indicate additional needs like a wheelchair van or escort in Section 7.
7. Finally, sign Section 8 to certify that all information is accurate before submitting your completed form.

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