| 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 |