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Get 90-Day Waiver Request Form 90-DWR - Mass.Gov - Mass

Acy and dental, please complete this form for every claim and attach applicable supporting documentation to each one. Effective April 1, 2013, 90-day waivers must be submitted electronically unless the provider has an approved electronic claims submission waiver. Ninety-day waiver requests must be submitted electronically via direct data entry (DDE) using delay reason code 1, 4, or 8. Date of Request: Provider Name: Provider Address: MassHealth Provider ID/Service Location: Reason for Request Yo.

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