Behavioral Health Forms
- 4031 MH-TCM Authorization to Release Protected Health Information to SCHA (doc) | 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.
- 1796 v3 MH-TCM Eligibility Notification Form (doc) | Used when requesting MH-TCM services.
- DHS-6069A-ENG MH-TCM Adult Diagnostic Verification Form (DHS Web Form)
- DHS-6069B-ENG MH-TCM Child/Adolescent Diagnostic Verification Form (DHS Web Form)
- 1922 v3 MH-TCM DTR Recommendation for Action Form (doc) | 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.
- 2281 v2 Behavioral Health Notification (doc) | Used to provide notification of ACT, Youth ACT, ARMHS, Crisis Services-Adult/Child, or Intensive Outpatient Mental Health Treatment services.
- 2284 v2 MH-TCM Universal Transfer Form (doc) | Used when member is receiving MH-TCM services and MH-TCM services are being transferred to another provider.
- 2285 v2 Outpatient Behavioral Health Authorization Form (doc) | 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).
- 2286 v2 CTSS Authorization Form (doc) | Used when requesting prior authorization for a CTSS services (crisis assistance, family therapy, group therapy, multi-family group, therapy) after threshold is met.
- 2287 v2 Initial Dialectical Behavior Therapy (DBT) Authorization Form (doc) | Used when requesting prior authorization for individual DBT therapy or group DBT skills training.
- 2288 v2 Additional Dialectical Behavior Therapy (DBT) Authorization Form (doc) | Used when DBT treatment is current in progress to request authorization for continued DBT services.
- 2290 v2 Eating Disorder In-Patient/Out-Patient Review Form (doc) | Used for both notification and requesting prior authorization for Eating Disorder In-Patient or Eating Disorder Out-Patient treatment.
- 2292 v2 Request for Psychological Testing Authorization Form (doc) | Used to request Neuropsychological Testing or Psychological Testing after threshold is met.
- 2324 v2 Behavioral Health Admission Worksheet (doc) | 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.
- Behavioral Health Home Service Eligibility Notification Form (doc)
Substance Use Disorder (SUD)
- 1761 v4 SUD Admission Form (doc) | Used for chemical dependency treatment, inpatient, outpatient, methadone.
- 1762 v4 SUD Request Worksheet (doc) | Used by Rule 25 Assessors only.
- 1763 v4 SUD Complexities Grid (doc) | To be submitted with SUD Admission Form For All Levels of Care at time of admission and if complexity changes.
- 2291 v2 Inpatient Notification Worksheet (doc) | Used when providing notification of Detox-inpatient for both admission and discharge.
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.
- Healthy Pathways Communication Form (doc) | To be submitted by eligible case manager to initiate, change, renew, or end the service
- Healthy Pathways Service Plan (doc) | Used to develop member-specific plans, including goals and interventions