Claims | Clinical/UM | COVID-19 Forms | 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
- 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
- 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
- Evaluator Participation at ISPT Meetings Verification Forms
- Independent Prescriber/Evaluator Registration Forms
- TSS Scheduling Initiative (Beaver, Butler, Crawford, Lawrence, Mercer and Venango Counties)
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
Multi-Systemic Therapy
Outpatient Review Form
Other Forms
- Grievance Release Form
- Integrated Care Release of Information
- Medical Exception Request Worksheet Form
- PCIT Fidelity Tool
- RTF Discharge Form
COVID-19 Temporary Registration Forms
- COVID-19 – ACT-CTT Registration
- COVID-19 – IP MH Registration
- COVID-19 – MDF and TI1 Service Classes Registration
- COVID-19 – MH IOP Registration
- COVID-19 – Mobile Medications Registration
- COVID-19 – PHP Registration
- COVID-19 – Primary Insurance Registration for Inpatient Mental Health
- COVID-19 – Psych Rehab Registration
- COVID-19 – SUD PHP Registration
- COVID-19 – SUD IOP Registration
- COVID-19 – FDRP Registration
- COVID-19 – ICM Registration
- COVID-19 – Family Based Registration
Network Management Forms
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