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 Services Intermediary Authorization Form
• UB-04 Claim Form

Clinical / Utilization Management Forms

Authorization Forms

• Acute Partial Hospitalization (APH) Auth Request Form
• Beaver County ACT/FACT Auth Request Form
• Fayette County Forensic Diversion Recovery Program (FDRP) Auth Request Form
• (HLOC) Higher Level Of Care Auth Request Form
• LTSR ITR
• Medication Management Form
• Methadone Maintenance Report Form
• PER Form
• ProviderConnect RFS Form
• Psych Rehab After-Service Plan
• Psych Rehab ARF
• Retro-Authorization Form
  

BHRS Forms

• 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 Service Delivery Schedule Form
• Plan of Care Summary Form
• Request for School Input Form
• Act 62 Fax Cover Sheets
  • Fayette County
  • All Other Counties
• Evaluator Participation at ISPT Meetings Verification Forms
  • Armstrong, Cambria, Greene, Indiana, Lawrence, Washington, and Westmoreland Counties
  • Beaver and Butler Counties
  • Erie County
  • NW3 Counties (Crawford, Mercer, and Venango)
• Independent Prescriber Registration Forms
  • Butler County
  • Lawrence County
  • NW3 Counties
• TSS Scheduling Initiative
  (Butler, Crawford, Lawrence, Mercer and Venango Counties)
  • TSS Scheduling Form
  • 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 8 Week Review Form
• Family Based Mental Health Services 16 Week Review Form
• Family Based Mental Health Services 24 Week Review Form
• Family Based Review Discharge Form

Family Focused/Solution Based Services Forms

• FFSBS Discharge Form Effective 0606
• FFSBS Precert Form Effective 0606
• FFSBS 6 Week Review Form Effective 0606
• FFSBS 16 Week Review Form Effective 0606
• FFSBS 24 Week Review Form Effective 0606

Medicare Primary Insurance Forms

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

MST Forms

• MST Initial Assessment
• MST Ongoing Review Form

Outpatient Review Form

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

Other Forms

• Grievance Release Form
• Medical Exception Request Worksheet Form
• Resource Guide for CareConnect

Network Management Forms

• Provider Update/Change of Address
  • Facilities
  • MDs/PhDs/DOs/CRNPs
  • Masters Level Individual Practitioners (LSWs, LCSWs, LMFTs, LPCs)
    • Supplemental Services Application
    • Supplemental Services Application Instructions
• 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

• Consumer Registry Form
• DPW Instructions - POMS
• POMS Quick Guide
• Quarterly Status Update Form

CCR POMS Non-HealthChoices

• CCR POMS Initial Consumer Registration Form
• CCR POMS Manual Version 1.02
• CCR POMS Quarterly Status Update Form

Provider Relations Forms

• Summer Therapeutic Activities Program Application

Quality Management Forms

• Critical Incident Log