Forms

Program-specific Forms (Appendix A)

Adverse Incident Report (Online Submission)

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) – All Counties (Online Submission) (updated version coming soon. Please see the below paper form and instructions.)

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)

Discharge Summary

IBHS Assessment

IBHS TAR Registration Cover Sheet

IBHS TAR Cover Sheet

IBHS Staffing Phone Consultation Form

IBHS Written Order – Updated Version

Initial Interview and Assessment

Initial Referral for Family Based Services

Incident Reporting Packet

ISPT Sign-In/Concurrence Form

LGBTQI Audit Tool

Life Domain Format Guidelines

Plan of Care Summary

Provider Access Form

Referral for IBHS Assessment

Request for Psychological Testing Preauthorization Form

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

Ad Hoc/Out-of-Network Provider Request

 

County-specific Forms (Appendix B)

No county-specific forms currently

 

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