Forms
Program-specific Forms (Appendix A)
Ad Hoc – Out of Network Provider Request
Adverse Incident Report (Online Submission)
Alternatives to Residential Mental Health Form, Attachment 8
ASAM Crosswalk with PA’s System of Care
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
Cultural Competence Implementation Audit Tool
DDAP – ASAM Placement Summary Form
Discharge Form (submitted via Magellan provider website)
IBHS TAR Registration Cover Sheet
IBHS Staffing Phone Consultation Form
IBHS Written Order – Updated March 9th, 2023
Initial Interview and Assessment
Initial Referral for Family Based Services
Request for Psychological Testing Preauthorization 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)
No county-specific forms currently
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