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 | |
|---|---|---|
| Mental Health | MH-TCM Eligibility Notification Form Used when requesting MH-TCM services. | 4532 (pdf) |
| Mental Health | MH-TCM Adult Diagnostic Verification Form | DHS-6069A-ENG (DHS Web Form) |
| Mental Health | MH-TCM Child/Adolescent Diagnostic Verification 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. | 4533 (doc) |
| Mental Health | Initial Behavioral Health Notification Used to provide notification of ACT, Youth ACT, IRTS, CMHRTS, Partial Hospitalization, or PRTF services. | 4398 (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). | 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. | 4390 (doc) |
| Mental Health | Early 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 Health | Initial 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 Health | Additional 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 Health | Dialectic Behavior Therapy (DBT) Form Used when requesting prior authorization for individual DBT therapy or group DBT skills training, or continued therapy. | 4498 (pdf) |
| 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. | 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. | 4395 (doc) |
| 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. | See SCHA Provider Service Authorization and Notification List for new form numbers. |
| Mental Health | Behavioral Health Home Service Eligibility Notification Form | 4537 (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 Documents | Diagnostic Assessment (DA) Report Components (pdf) | DA Report Components (website) |
| Resource Documents | 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. | 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 & Process | 4383(pdf) |
| Healthy Pathways Provider Billing Process | 4382 (pdf) |