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Frequently Used Forms

Behavioral Health Outpatient Detoxification Service Request Form

Behavioral Health Residential Detoxification Service Request Form

Behavioral Health Residential Substance Abuse Treatment Service Request Form

Behavioral Health Substance Abuse Counseling Extension Request Form

Behavioral Health Service Injection Authorization Form

Behavioral Health Service Request Form

Behavioral Health STAR & STAR+PLUS Substance Use Disorder Quick Reference Guide

Quick Reference Guide

Prior Authorization Guide

Service Request/Prior Authorization Form

Synagis Prior Authorization Form

CHIP/Behavorial Health Prior Authorization Guide

STAR/STAR+PLUS Behavorial Health Prior Authorization Guide

Outpatient Psychological/Neuropsychological Testing Request Form

Extended Psychotherapy/Counseling Request Form

Inpatient Psychiatric Admission Request Form

Extended Inpatient Psychiatric Admission Request Form

Obstetrical Service Request Form

Disease Management Referral

Psychiatric Inpatient Discharge Form

Notification of Authorized Services Form

Authorization Number Form

Change of Information Form for 5010 Transition

Change of Information Form

Claims Adjustment Form

Contract Request Form

*Please visit the EDI section for ERA/EFT enrollment forms

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