Provider Resources

Program-specific Forms (Appendix A)

Alternatives to Residential Mental Health Form, Attachment 8

ASAM Crosswalk with PA's System of Care

Children in Substitute Care (CISC) Referral Form

Consent to Release Protected Health Information (PHI) - English

Consent to Release Protected Health Information (PHI) - Spanish

Cultural Competence Implementation Audit Tool

Discharge Form (submitted via Magellan provider website)

Discharge Summary

Family Based Services Discharge Form

Initial Referral for Family Based Services

Incident Reporting Packet

ISPT Sign-In/Concurrence Form

LGBTQI Audit Tool

Life Domain Format Guidelines

Mental Health Services in School Coordination Form

PCP Communication Form

Plan of Care Summary

Provider Access Form

Request for Psychological Testing Preauthorization Form

Treatment Authorization Request Cover Sheet

Treatment Authorization Request Form

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

Ad Hoc/Out-of-Network Provider Request

 

County-specific Forms (Appendix B)

Bucks County CQC Treatment Authorization Request Cover Sheet

Bucks, Delaware and Montgomery County Referral for BHRS Services

Cambria County BHRS Brief Intervention TAR Cover Sheet

Delaware County CQC Treatment Authorization Request Cover Sheet

Delaware County EAS CQC Treatment Authorization Request Cover Sheet

Lehigh, Northampton, Cambria County Request for Reauthorization – Family-Based Services

Lehigh, Northampton County EI BHRS Treatment Authorization Request Cover Sheet

Montgomery County CQC Treatment Authorization Request Cover Sheet

Montgomery County EAS CQC Treatment Authorization Request Cover Sheet

 

The Adobe Reader is required to view PDF files.