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Forms

Below are forms for providers. Fillable forms open the best using Internet Explorer.


Behavioral Health

  • Client placement authorization (PDF)
    Download
  • Diagnostic assessment (PDF)
    Download
  • Mental health TCM notification form (PDF)
    Download
  • Psychological testing form (PDF)
    Download
  • Service authorization form for ARHMS, IRTS and ACT services (DOC)
    Download

Claims and payment

  • Automated clearinghouse ACH funds transfer request (DOC)
    Download
  • Claims adjustment reconsideration request (PDF)
    Download
  • Client placement authorization (PDF)
    Download
  • Non-contracted provider information form
    Download
  • Provider appeal form (PDF)
    Download
  • W9 for contracted providers (PDF)
    Download
  • W-9 for non-contracted providers (PDF)
    Download

Contracting and credentialing

  • Contracted provider information form (PDF)
    Download
  • Disclosure of ownership changes form (PDF)
    Download
  • Facility credentialing application (PDF)
    Download
  • Location add/term/change form (PDF)
    Download
  • Location and practitioner template roster (XLS)
    Download
  • Network contract request form (PDF)
    Download
  • Practitioner initial credentialing application (PDF)
    Download
  • Practitioner re-credentialing application (PDF)
    Download
  • Practitioner add/term/change form (PDF)
    Download
  • Quarterly complaint form (DOCX)
    Download
  • Site visit checklist (PDF)
    Download

Pharmacy

  • Drug reconsideration request (PDF)
    Download
  • Prescription drug prior authorization form (PDF)
    Download

Release of information

  • Patient authorization for release of information form (PDF)
    Download

Restricted recipient

  • Medical referral for MRRP members (PDF)
    Download

Service authorizations

  • Advanced recipient notice of non-covered service-item
    Download
  • Continuity of care (PDF)
    Download
  • Inpatient admission notification (PDF)
    Download
  • Neuropsych testing service authorization form (DOC)
    Download
  • Partnered provider out-of-network referral (PDF)
    Download
  • Psychological testing form (PDF)
    Download
  • Service authorization request (PDF)
    Download
  • Service authorization request form for ARHMS, IRTS and ACT services (DOC)
    Download
  • Substitute health service request form (PDF)
    Download

Provider updates

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Provider updates

Electronic transaction guidelines

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