Provider Forms

Claims | Clinical/UM | Network Mgt | NWBHP | POMS | Provider Relations | Quality Mgt

Claims Dept Forms

• Claims Batch Header Form
• CMS-1500 Claim Form
• NPI Notification Letter
• NPI Submission Form – Individual Practitioner
• NPI Submission Form – Organizational Provider
• Online Services Account Request Form
• Online Account Request Form – Access for Multiple Providers
• Online Services Intermediary Authorization Form
• UB-04 Claim Form

Clinical / Utilization Management Forms

Authorization Forms

• ACT CTT Continued Stay Request
• ACT CTT Pre-Certification Request
• Acute Partial Hospitalization (APH) Auth Request Form
• Adult Non-Acute Partial Hospitalization Pre-Cert Authorization Request
• Adult Non-Acute Partial Hospitalization Continued Stay Authorization Request
• ASAM Cover Page for Substance Use Auth Requests
• Authorization Request Form for ASAM 1.0
• Authorization Request Form for ASAM 2.1
• Authorization Request Form for ASAM 2.5
• Case Conceptualization Tool (Greene, Fayette and Beaver Counties only)
• Child/Adolescent Partial Hospitalization Pre-Cert Authorization Request
• Child/Adolescent Partial Hospitalization Continued Stay Authorization Request
• Child/Adolescent School-Based Partial Hospitalization Pre-Cert Authorization Request
• Child/Adolescent School-Based Partial Hospitalization Continued Stay Authorization Request
• Fayette County Forensic Diversion Recovery Program (FDRP) Auth Request Form
• HLOC Substance Use Authorization Request Form – Pre-Cert
• HLOC Substance Use Authorization Request Form – Continued Stay 
• LTSR Continued Stay Request
• LTSR Pre-Certification Request
• Medication Management Form
• Methadone Maintenance Precert
• Methadone Maintenance Continued Stay Review
• Methadone Maintenance Discharge
• Psych Rehab Pre-Cert Form
• Psych Rehab Continued Stay Request
• Psychological Evaluation Request (PER) Form
  • List of Psychological Tests
• ProviderConnect RFS Form
• Retro-Authorization Form
• RTF Request for Hold Bed Days

BHRS Forms

• BHRS Packet Submission Timelines
• BHRS Sample Packet with Instructions
• BHRS Service Descriptions Format
• BHRS Authorization Correction Form
• BHRS Continuation Rights Form
• BHRS Family Choice/Confirmation Form
• BHRS ISPT Sign-In Form
• BHRS Initial ISPT Summary Form
• BHRS Ongoing ISPT Summary Form
• BHRS Initial ISPT Summary Form – Westmoreland County Only
• BHRS Ongoing ISPT Summary Form – Westmoreland County Only
• BHRS Service Delivery Schedule Form
• Plan of Care Summary Form
• Request for School Input Form
• Site Based Autism Fax Cover Sheet
• New and Revised BHRS and BHRS Exception Service Descriptions Cover Sheet and Checklist
• Amendment Requests for BHRS and BHRS Exception Service Descriptions Cover Sheet and Checklist for Non-Clinical Changes
• Act 62 Fax Cover Sheets
  • Fayette County
  • All Other Counties
• Evaluator Participation at ISPT Meetings Verification Forms
  • Armstrong, Greene, Indiana, Washington, and Westmoreland Counties
  • Beaver and Butler Counties
  • Fayette County
  • NW3 Counties (Crawford, Lawrence, Mercer, and Venango)
• Independent Prescriber/Evaluator Registration Forms
  • Beaver County
  • Butler County
  • Lawrence County
  • NW3 Counties
• TSS Scheduling Initiative (Beaver, Butler, Crawford, Lawrence, Mercer and Venango Counties)
  • TSS Scheduling Form
  • TSS Schedule Form Instructions – Beaver County
  • TSS Schedule Form Instructions – Butler, Crawford, Lawrence, Mercer and Venango Counties
  • TSS Service Delivery Schedule: Long-Term Schedule Change
  • TSS Service Delivery Schedule: Temporary Schedule Change

Family Based Mental Health Services

• Family Based Review Process Instructions
• FBMHS Recommendation
• Family Based Review Precert Form
• Family Based Mental Health Services 16 Week Review Form
• Family Based Mental Health Services 24 Week Review Form
• Family Based Review Discharge Form
• How to Request Family Based Services Authorizations via ProviderConnect

Medicare Primary Insurance Forms

• Medicare Primary Insurance Notification ITR
• Medicare Primary Insurance DC Form

Multi-Systemic Therapy

• MST Process
• How to Request MST via ProviderConnect
• MST Assessment Form for ProviderConnect

Outpatient Review Form

• Mobile Medications ORF2
• ORF Instructions
• Outpatient D&A ORF
• Outpatient Psych ORF

Other Forms

• Grievance Release Form
• Integrated Care Release of Information
• Medical Exception Request Worksheet Form
• PCIT Fidelity Tool
• RTF Discharge Form

Network Management Forms

• For ALL Provider Updates/Change of Address
• W-9 Substitute Form

Northwest Behavioral Health Partnership Forms

(These forms are for NWBHP ONLY – Serving Crawford, Mercer, & Venango Counties)

• BHRS Discharge Form (Crawford County)
• BHRS Discharge Form (Mercer County)
• BHRS Discharge Form (Venango County)
• Independent Prescriber Registration Form
• Independent Prescriber ISPT Participation Form
• Request for BSC/MT Input Form

POMS Forms

HealthChoices POMS

• POMS: Submit Online via ProviderConnect
• DHS Instructions – POMS

Provider Relations Forms

• Rate Review Request Form
• Summer Therapeutic Activities Program Application

Quality Management Forms

• Table of Incidents
• Critical Incident Log
• Critical Incident – Code 255.5 Clarification
• Critical Incident Reporting PowerPoint