Document Title Document Type Document Size Last Updated
Health Care Professional Forms (Appendix D)
Behavioral Treatment Record Review Tool PDF 163KB 11/21/2018
Coordination of Benefits PDF 17KB 08/01/2013
EAP Clinical Assessment Form PDF 40KB 08/01/2013
EAP Statement of Understanding PDF 2.44MB 08/01/2013
ED IOP Concurrent Review Form PDF 27KB 08/01/2013
Electronic Payment and Remittance Reports Online Resource -- 05/22/2014
HCFA/CMS 1500 Online Resource -- 04/03/2015
Informed Consent Form PDF 14KB 08/01/2013
Member Release of Information Form PDF 96KB 08/01/2013
MH IOP Concurrent Review Form PDF 26KB 08/01/2013
Provider Self-Introduction Form PDF 173 KB 05/09/2019
SA IOP Concurrent Review Form PDF 28KB 08/01/2013
Self-Pay Agreement PDF 15KB 08/01/2013
Specialty Attested Form PDF 317kB 04/11/2019
Specialty Attestation for Participation PDF 96KB 08/01/2013
Specialty Verified Form PDF 172kB 03/07/2019
Termination Form (Individually Contracted Providers) PDF 181 KB 10/09/2018
W-9 Form PDF 54KB 08/01/2013