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 Category||Form Name & Description||Use for 2018 & earlier dates of service||Use for 2019 & later dates of service|
|Mental Health||MH-TCM Authorization to Release Protected Health Information to SCHA|
Used when member consents to have another entity release information to SCHA for purposes of determining eligibility for MH-TCM services and to be able to approve claims payments.
|Mental Health||MH-TCM Eligibility Notification Form|
Used when requesting MH-TCM services.
|4376 (doc)||4532 (pdf)|
|Mental Health||MH-TCM Adult Diagnostic Verification Form||DHS-6069A-ENG (DHS Web Form)||DHS-6069A-ENG (DHS Web Form)|
|Mental Health||MH-TCM Child/Adolescent Diagnostic Verification Form||DHS-6069B-ENG (DHS Web Form)||DHS-6069B-ENG (DHS Web Form)|
|Mental Health||MH-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.
|4379 (doc)||4533 (doc)|
|Mental Health||Initial Behavioral Health Notification|
Used to provide notification of ACT, Youth ACT, IRTS, CMHRTS, or PRTF services.
|2281 v2 (doc)||4398 (pdf)|
|Mental Health||MH-TCM Universal Transfer Form|
Used when member is receiving MH-TCM services and MH-TCM services are being transferred to another provider.
|4380 (doc)||4534 (pdf)|
|Mental Health||Behavioral 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).
|2285 v2 (doc)||4381 (doc)|
|Mental Health||CTSS 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.
|2286 v2 (doc)||4390 (doc)|
|Mental Health||Initial Dialectical Behavior Therapy (DBT) Authorization Form |
Used when requesting prior authorization for individual DBT therapy or group DBT skills training.
|2287 v2 (doc)||Discontinued for 2019 dates of service, use form 4498 (pdf)|
|Mental Health||Additional Dialectical Behavior Therapy (DBT) Authorization Form |
Used when DBT treatment is current in progress to request authorization for continued DBT services.
|2288 v2 (doc)||Discontinued for 2019 dates of service, use form 4498 (pdf)|
|Mental Health||Dialectic Behavior Therapy (DBT) Form|
Used when requesting prior authorization for individual DBT therapy or group DBT skills training, or continued therapy.
|Mental Health||Eating 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.
|2290 v2 (doc)||Notification and authorization no longer required.|
|Mental Health||Request for Psychological Testing Authorization Form|
Used to request Neuropsychological Testing or Psychological Testing after threshold is met.
|2292 v2 (doc)||4395 (doc)
As of 2/1/19 prior authorization is no longer required for Psychological Testing. Please use this form for claims from 1/1/19 to 1/31/19.
|Mental Health||Behavioral 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.
|2324 v2 (doc)||See SCHA Provider Service Authorization and Notification List for new form numbers.|
|Mental Health||Behavioral Health Home Service Eligibility Notification Form||Behavioral Health Home Service Eligibility Notification Form (doc)||4537 (pdf)|
|Mental Health||Inpatient Admit & Discharge Notification Form |
Used when providing notification of an admission or discharge of an acute care hospitalization.
|2291 v2 (doc)||4492 (pdf)|
|Resource Documents||Diagnostic Assessment (DA) Report Components (pdf)||DA Report Components (website)||DA Report Components (website)|
|Resource Documents||Standard Diagnostic Assessment (DA) Tool (doc)||Standard 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.
|1761 v4 (doc)||4505 (pdf)|
|Substance Use Disorder (SUD)||SUD Request Worksheet (doc)|
Used by Rule 25 Assessors only.
|1762 v4||4506 (pdf)|
|Substance Use Disorder (SUD)||SUD Complexities Grid (doc)||1763v4 (doc)||4507 (pdf)|
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||Use for 2018 & earlier dates of service||Use for 2019 & later dates of service|
|Healthy Pathways Communication Form |
To be submitted by eligible case manager to initiate, change, renew, or end the service
|4385 (doc)||4536 (doc)|
|Healthy Pathways Service Plan|
Used to develop member-specific plans, including goals and interventions
|Health Pathways Service Plan||4384 (doc)|
|Healthy Pathways Program Criteria & Process||4383(pdf)||4383(pdf)|
|Healthy Pathways Provider Billing Process||4382 (pdf)||4382 (pdf)|