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South Country Health Alliance | Behavioral Health Forms

Behavioral Health Forms

Can’t find a form on this page? Try the looking in the provider portals. The portals can house several provider forms, including credentialing forms, authorization forms, and other provider network forms. If YOU ARE A NON-CONTRACTED PROVIDER authorizations and claims will not process until you complete the provider forms found on the Non-Contracted Providers page.

Form CategoryForm Name & Description 
Mental HealthMH-TCM Eligibility Notification Form
Used when requesting MH-TCM services.
4532 (pdf)
Mental HealthMH-TCM Adult Diagnostic Verification FormDHS-6069A-ENG (DHS Web Form)
Mental HealthMH-TCM Child/Adolescent Diagnostic Verification FormDHS-6069B-ENG (DHS Web Form)
Mental HealthMH-TCM DTR Recommendation for Action Form
To be submitted in addition to the MH-TCM Eligibility Determination Notification Form when a member is determined ineligible at time of request for MH-TCM services. Also to be submitted when a member is receiving MH-TCM services and services will be terminated.
4533 (doc)
Mental HealthInitial Behavioral Health Notification
Used to provide notification of ACT, Youth ACT, IRTS, CMHRTS, Partial Hospitalization, or PRTF services.
4398 (pdf)
Mental HealthBehavioral Health Authorization Form
Used when requesting prior authorization for Adult Day Treatment, ARMHS (after threshold is met), Certified Peer Specialist (after threshold is met), Adult Crisis Response Services–Residential Crisis Stabilization, Intensive Outpatient Mental Health Treatment (after threshold is met), Partial Hospitalization (after threshold is met), and Psychotherapy (after threshold is met).
4381 (doc)
Mental HealthCTSS Authorization Form
Used when requesting prior authorization for a CTSS services (crisis assistance, family therapy, group therapy, multi-family group, therapy) after threshold is met.
4390 (doc)
Mental HealthEarly Intensive Developmental and Behavior Intervention (EIDBI) Authorization Form
Used to request authorization for EIDBI services. The form can also be used to request prior authorization for EIDBI services after the threshold has been met.
4894 (pdf)
Mental HealthInitial Dialectical Behavior Therapy (DBT) Authorization Form
Used when requesting prior authorization for individual DBT therapy or group DBT skills training.
Discontinued for 2019 dates of service, use form 4498 (pdf)
Mental HealthAdditional Dialectical Behavior Therapy (DBT) Authorization Form
Used when DBT treatment is current in progress to request authorization for continued DBT services.
Discontinued for 2019 dates of service, use form 4498 (pdf)
Mental HealthDialectic Behavior Therapy (DBT) Form
Used when requesting prior authorization for individual DBT therapy or group DBT skills training, or continued therapy.
4498 (pdf)
Mental HealthEating Disorder In-Patient/Out-Patient Review Form
Used for both notification and requesting prior authorization for Eating Disorder In-Patient or Eating Disorder Out-Patient treatment.
Notification and authorization no longer required.
Mental HealthRequest for Psychological Testing Authorization Form
Used to request Neuropsychological Testing or Psychological Testing after threshold is met.
4395 (doc)
Mental HealthBehavioral Health Admission Worksheet
Used when providing notification or requesting prior authorization of Acute Inpatient Mental Health, IMD, Partial Hospitalization, or Rule 5 Children's Residential Treatment services. Also used when requesting prior authorization for IRTS after threshold is met.
See SCHA Provider Service Authorization and Notification List for new form numbers.
Mental HealthBehavioral Health Home Service Eligibility Notification Form4537 (pdf)
Mental Health/Substance Use Disorder (SUD)Inpatient Admit & Discharge Notification Form
Used when providing notification of an admission or discharge of an acute care hospitalization, inpatient acute SUD rehabilitation, and inpatient detoxification.
4492 (pdf)
Resource DocumentsDiagnostic Assessment (DA) Report Components (pdf)DA Report Components (website)
Resource DocumentsStandard Diagnostic Assessment (DA) Tool (doc)Standard Diagnostic Assessment (DA) Tool (doc)
Substance Use Disorder (SUD)SUD Admission & Discharge Form
Used for chemical dependency treatment, inpatient, outpatient, methadone.
4505 (pdf)
Substance Use Disorder (SUD)SUD Request Worksheet (doc)
Used by Rule 25 Assessors only.
4506 (pdf)
Substance Use Disorder (SUD)SUD Complexities Grid (doc) 4507 (pdf)

Healthy Pathways

Healthy Pathways is a program to assist members in preventing mental health deterioration through early intervention and education. This program can also be used as a transition service for those requiring a maintenance level of service or for members who qualify for MH-TCM but opt to use an alternative service instead. Please utilize the following forms to request this service.

Form Name & Description 
Healthy Pathways Communication Form
To be submitted by eligible case manager to initiate, change, renew, or end the service
4536 (doc)
Healthy Pathways Service Plan
Used to develop member-specific plans, including goals and interventions
4384 (doc)
Healthy Pathways Program Criteria & Process4383(pdf)
Healthy Pathways Provider Billing Process4382 (pdf)