Contacts

Provider Forms

The following forms are provided as a convenience to our clients. We cannot guarantee that any form is the most current version, nor that it will be accepted by an insurance company.

Most forms are PDF files; the remainder are Microsoft Word documents. The free Adobe Reader (version 5.x minimum) is required to view, fill in, and print PDF forms. If you don’t have Adobe Reader installed on your computer or need to upgrade your copy, click the button below to go to the Adobe Reader download site:

When you click on one of the underlined links below, the form will be displayed in your Web browser. To print the form, click the printer icon on the Adobe Reader toolbar just above the top of the form (not your Internet browser’s toolbar).

Authorization Request and Treatment Plan Forms

Anthem Blue Cross of California
Behavioral Health Treatment Plan
Behavioral Health Medical Necessity Criteria
Individual Authorization for Release of PHI from Provider to Anthem
Psychotherapy Notes Authorization for Release of PHI from Provider to Anthem
Behavioral Health Consent to Exchange Information Between Providers
Anthem Blue Cross and Blue Shield of Virginia
Standard 3-page authorization request (print in landscape)
Fillable single page version
Federal Employee Program
Non-Anthem providers treating Anthem members
Psychological/Neuropsychological Testing Request
Psychotherapy Notes Authorization
Blue Cross of Idaho New!

BlueCross BlueShield of New Mexico

CareFirst BlueCross BlueShield of the National Capital Area
Request additional sessions online - including FEP
Instructions for DC and MD Uniform Treatment Plans
District of Columbia Uniform Treatment Plan
District of Columbia Uniform Treatment Plan (Fillable)
Maryland Uniform Treatment Plan
Maryland Uniform Treatment Plan (Fillable)
Corphealth
Initial Outpatient Clinical Review Form
Concurrent Outpatient Clinical Review Form
Request for Psychological Testing
Neuropsychological Testing Request Form
Medication Management Outpatient Clinical Review Form
Coordination of Care Form (Humana HMO)
Utilization Review Guide
District of Columbia Uniform Treatment Plan (Fillable)

Empire BlueCross BlueShield
Outpatient Treatment Report
Psychological Testing Authorization Form
Federal Employee Program (FEP) in the Mid-Atlantic States

Interface EAP Clinical Feedback Form

Magellan Behavioral Health
Request additional sessions online - including FEP
Instructions for DC and MD Uniform Treatment Plans
District of Columbia Uniform Treatment Plan
District of Columbia Uniform Treatment Plan (Fillable)
Maryland Uniform Treatment Plan
Maryland Uniform Treatment Plan (Fillable)
Treatment Request Form (may not apply to all states)
Request for Psychological/Neuropsychological Testing Instructions
Request for Psychological/Neuropsychological Testing
Request for Psychological/Neuropsychological Testing (Fillable)
PCP Communication Form
Maryland Uniform Treatment Plan (Fillable)

Mental Health Network, Inc. (MHNet)

Mesa Mental Health

Minnesota Universal Outpatient Mental Health Authorization Form

Mutual of Omaha

New Directions Behavioral Health

Optima Health (formerly Sentara Behavioral Health Services)
Individual Service Plan Form
Medication Treatment Report Form
Psychological & Neuropsychological Testing Request Form
Other Forms
Scott & White Behavioral Health Authorization Request Form

TRICARE North Region
Online Authorization and Referral Submission (Registration required)
Service Request Form (Fillable Microsoft Word)
Other Health Insurance (OHI) Questionnaire Form
Request for Non-Covered Services (Fillable)
Case Management Referral Form (MS Word)
TRICARE South Region
Outpatient Treatment Report
Retrospective Review Form
Request for Psychological/Neuropsychological Testing
Authorization for Release of Information
Consult Report
Other Health Insurance (OHI) Questionnaire Form
Non-Covered Services Waiver Form
Case Management Referral Form
TRICARE West Region
Preauthorization for Outpatient Treatment Request (MS Word)
Preauthorization for Psychological/Neuropsychological Testing (MS Word)
Other Health Insurance (OHI) Form (English)
Other Health Insurance (OHI) Form (Spanish)
Primary Care Manager (PCM) Communication Form (MS Word)
Case Management Patient Referral Form
United Behavioral Health
Initial Wellness Assessment (Adult)
Initial Wellness Assessment (Child & Adolescent)
Psychological/Neuropsychological Testing Request
Psychological/Neuropsychological Testing Request (Fillable)
ValueOptions
Outpatient Registration Form (ORF1)
Medication Management Registration Form
Psychological/Neuropsychological Evaluation Request
List of Psychological/Neuropsychological Tests
Virginia Medicaid
KePRO iExchange (online submission)
KePRO How to Submit an Outpatient Psychiatric Services Request
DMAS-363 - Outpatient Prior Authorization Request Form (MS Word)
DMAS-363 - Outpatient Prior Authorization Request Form