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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 Update: December 9, 2011