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MassHealth Adult Foster Care PCP Order Form

MassHealth requires this order before granting prior authorization for Adult Foster Care. The AFC provider agency records the member's needs against the criteria in 130 CMR 408.000: daily hands-on help or cueing for six activities of daily living, five behavior items, and the diagnosis with signs and symptoms. The member's primary care provider then reviews, verifies and signs it as the prescribing provider.

Who completes it

The AFC provider completes Section I, and its RN or NP signs the provider attestation. The member's PCP (MD, DO, NP or PA) reviews Section I, then completes Section II with their name, MassHealth provider ID, NPI and the prescribing provider attestation.

Submitting and payment

How to submit it
Return the signed form to the AFC provider agency named on it, which uses it to request prior authorization from MassHealth.

Good to know

  • Bathing, dressing, toileting, transferring, mobility and eating are each marked for daily hands-on assistance and for cueing and supervision throughout the activity, following the AFC Medical Necessity Guidelines.
  • The behavior items are wandering, verbally abusive, physically abusive, and socially inappropriate or disruptive behavior, plus resisting care. The diagnosis and symptoms should support the need for AFC.
  • The PCP must be enrolled with MassHealth, as a fully participating or nonbilling provider, because ACA Section 6401(b) requires the ordering provider's NPI on the AFC claim.
  • Both attestations certify the medical necessity information under 130 CMR 408.416 and 450.204, with civil or criminal penalties for falsification. The current fillable version is AFC-PCP-2-0421.

Get the official form

Download the current version from the source each time; forms change without notice.

MassHealth Adult Foster Care Primary Care Provider (PCP) Order Form

Official pagePDF

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who completes the MassHealth Adult Foster Care PCP order?

Both the agency and the PCP. The AFC provider fills in Section I, the member's ADL, behavior and diagnosis information, and its RN or NP signs. The member's PCP, an MD, DO, NP or PA, reviews and verifies that information, adds their provider details in Section II and signs the prescribing provider attestation.

Does the PCP need to be enrolled in MassHealth?

Yes. MassHealth requires AFC services to be ordered, referred or prescribed by an enrolled provider. Under ACA Section 6401(b), the AFC provider's claim must include the ordering provider's NPI, and that provider must be actively enrolled with MassHealth, either as a fully participating provider or as a nonbilling provider.

Is the AFC PCP order the same as the Group Adult Foster Care order?

No. MassHealth publishes separate PCP order forms for Adult Foster Care, Group Adult Foster Care and Adult Day Health, each tied to its own program's medical necessity criteria. The PCP should sign the form that matches the program the agency is requesting prior authorization for.