Behavioral Health Forms

Appointment of Representative
Authorization for Release of Information (General)
Authorization for Release of Information (Sensitive)
Case Management Behavior Health Referral Form
Clinical Expertise/Specialties
Comprehensive Suicide Risk Assessment
Consult Report Form
ECT Request Form
Letter of Referral
Non-Covered Services Waiver Form
OP Substance Abuse Rehab Group Therapy Request
Outpatient Treatment Report
Provider Address Change
Psych and Neuro Psych Testing
Residential Treatment Center Application
Retro Outpatient Treatment Report
Suicide Risk Assessment Form
TRICARE Dental Anesthesia Facility Prior Authorization Request
TRICARE Higher Level of Care Treatment Report
TRICARE Higher Level of Care Treatment Report (RTC Only)
Waiver of Benefit Request - In Patient
Waiver of Benefit Request - Psych-PHP
Waiver of Benefit Request - RTC
Waiver of Benefit Request - Substance Abuse

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Last Reviewed: June 30, 2010