Forms

Program-specific Forms (Appendix A)

Ad Hoc – Non-Participating (Non-Par) Forms

• Ad Hoc – Out of Network Provider Request (Do NOT use for Mental Health or Drug & Alcohol Outpatient)
• NEW! Drug & Alcohol Outpatient Non-Par Form (Online Submission)
• Mental Health Outpatient Non-Par Form (Online Submission)
  • Provider Tutorial – Mental Health Outpatient Non-Par Form Submission

Adverse Incident Report (Online Submission) 

Alternatives to Residential Mental Health Form, Attachment 8

Consent to Release Protected Health Information (PHI) – All Counties (Online Submission)

Consent to Release Protected Health Information (PHI) – English

Consent to Release Protected Health Information (PHI) – Spanish

DDAP – ASAM Placement Summary Form

Discharge Form (submitted via Magellan provider website)

Discharge Summary

IBHS Assessment

IBHS Authorization Request Checklist

IBHS TAR Registration Cover Sheet

IBHS TAR Facesheet for Individual ABA IBHAS

IBHS TAR Facesheet for Group IBHS

IBHS Staffing Phone Consultation Form

IBHS Written Order – Updated March 9th, 2023

Initial Interview and Assessment

Initial Referral for Family Based Services

ISPT Sign-In/Concurrence Form

Life Domain Format Guidelines

Mental Health/Intellectual Disability – Autism Assessment Tool

Plan of Care Summary

Provider Access Form

Provider Tax ID Change

Referral for IBHS Assessment

Request for Psychological Testing Preauthorization Form

Retrospective Review Form

• Instructions for Retrospective Review Form

Treatment Authorization Request Cover Sheet – Other Services

Treatment Authorization Request Form

Treatment Authorization Request Form for 90837 Mental Health and Substance Use Disorder

 

County-specific Forms (Appendix B)

Lehigh and Northampton County:
Case Management and/or Certified Peer Specialist Referral Application (Adult)
Case Management and/or Certified Peer Specialist Referral Application (Youth) 

 

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