Medical authorization and other forms
Medical authorization forms
- Behavioral health intensive outpatient or partial hospitalization authorization request form (PDF)
- Behavioral health substance use disorder (SUD) prior authorization form (PDF)
- Medical prior authorization form (PDF)
Use this form for all medical-related prior authorization requests.
- OB authorization/notification form (PDF)
- Outpatient treatment request form (PDF)
Use this form to request initial or extended authorization for outpatient services (after the initial 10 sessions of direct access services) or day treatment programs.
- Psychological/neuropsychological testing request form (PDF)
Use this form to request authorization for psychological or neuropsychological testing.
Other forms
- Autism spectrum disorder (ASD) treatment request form (PDF)
- Behavioral health discharge note (PDF)
- Behavioral health fax form (PDF)
- Code of ethics and conduct certification and conflicts of interest disclosure (PDF)
- Discharge planning form (PDF)
- Discharge planning quick reference sheet (PDF)
- Electronic funds transfer authorization agreement - Dental (PDF)
- Level of (transportation) need assessment form (PDF)
- Enrollee PCP designation form (PDF)
- Enrollee reward fax request form (PDF)
- Non-participating provider form (PDF)
- PCP maximum capacity notice form (PDF)
- Prescriber/practitioner addition to formulary request form (PDF)
- Provider change form (PDF)
- Provider data intake form (PDF)
- Psychiatric residential treatment facility referral form (PDF)
- School-based dental sealant program referral form (PDF)
- Substance use discharge note (PDF)
- Transportation request form (PDF)