Behavioral Health Forms

Document Title Document Type Document Size Last Updated
Behavioral Health Forms
Test - Applied Behavior Analysis (ABA) Assessment Form PDF 280 kB 07/08/2020
Applied Behavior Analysis (ABA) Prior Authorization Form PDF 307 kB 07/08/2020
CALAP - Request-Refuse Interpretation Services - English PDF 405 KB 09/13/2013
CALAP - Request-Refuse Interpretation Services - Spanish PDF 24 KB 09/13/2013
CALAP - Request-Refuse Interpretation Services - Chinese PDF 97 KB 09/13/2013
Coordination of Benefit PDF 17KB 08/01/2013
EAP Clinical Assessment Form PDF 358KB 08/27/2013
EAP Statement of Understanding PDF 2.44MB 04/01/2013
HCFA/CMS 1500 Online Resource -- 02/03/2015
Health Care Professional Directory Changes Online Resource -- 04/07/2020
Informed Consent Form PDF 14KB 08/01/2013
IOP Request Form PDF 282kB 06/04/2020
Medical Record Review Tool PDF 41KB 08/01/2013
Member Release of Information Form PDF 63.5KB 02/28/2017
Outpatient Behavioral Network Exception Request Form PDF 266KB 06/19/2020
Self-Pay Agreement PDF 15KB 08/01/2013
Specialty Attested Form PDF 400 KB 05/04/2020
Specialty Attestation for Participation* PDF 96KB 08/01/2013
Specialty Verified Form PDF 177kB 10/16/2019
Transcranial Magnetic Stimulation (TMS) Request Form PDF 383kB 04/15/2020
Treatment Record Review Tool PDF 157kB 08/17/2020
W-9 Form PDF 54KB 08/01/2013
Document Title Document Type Document Size Last Updated
State-Specific Forms
Florida Prior Authorization Form Online Resource -- 06/08/2017
Florida Prior Authorization Form – Instructions Online Resource -- 06/08/2017
Indiana Prior Authorization Form Online Resource -- 04/01/2016
Maryland Uniform Treatment Plan Form PDF 224kB 04/15/2020
Massachusetts Prior Authorization Form Online Resource -- 11/22/2016
Massachusetts Prior Authorization Form - Transcranial Magnetic Stimulation Online Resource -- 04/01/2016
Massachusetts Psychological and Neuropsychological Assessment Supplemental Form PDF 107kB 05/24/2019
New Mexico Prior Authorization Form PDF 222kB 04/17/2020
Tennessee ABA Assessment Request Form PDF 283kB 08/27/2020
Tennessee ABA Prior Authorization Form PDF 278kB 08/27/2020
Tennessee IOP Request Form PDF 277kB 08/17/2020
Tennessee Transcranial Magnetic Stimulation (TMS) Form PDF 282kB 08/17/2020
Texas Prior Authorization Form PDF 586.5kB 09/17/2019
Vermont Medical Prior Authorization Form Online Resource -- 12/24/2015
West Virginia Prior Authorization Form Online Resource -- 11/20/2019