Formulaires cliniques

Outpatient Treatment Report Forms

For most efficient and timely service – use of authorization request flow on our provider portal is the preferred method of submitting requests. Faxed or mailed forms should only be submitted to the specific fax or address. Please confirm for a specific contract that forms are allowed. Some contracts allow only telephonic review if web service is not utilized. Some contracts require that requests only be submitted via the web.

Inpatient and Higher Levels of Care Authorization Requests

For most efficient and timely service — use of authorization request flow on our provider portal is the preferred method of submitting requests. Beacon Health Options is no longer accepting faxed Inpatient Treatment Review (ITR) requests for Acute Mental Health or Acute Detox Services for its commercial contracts.

Please submit requests via our secure HIPAA-compliant provider portal. Alternatively, you may contact us by dialing the toll-free number on the member’s health benefit insurance card to complete a telephonic review during normal business hours Monday through Friday. After hour requests, occurring past normal business hours on Friday or Saturday, may be called in as well.

Continue to submit Residential, Partial, and Intensive Outpatient service requests online. If you are unable to complete the request online, please contact customer service by dialing the toll-free number on the member’s health benefit insurance card to obtain information on the correct procedure to utilize.

Faxed or mailed forms should only be submitted to the specific fax or address. Please confirm for a specific contract that forms are allowed. Some contracts allow only telephonic review if web service is not utilized. Some contracts require that requests only be submitted via the web.

Member Safety Referrals

Beacon is committed to ensuring that Beacon members receive safe, high quality care. Towards that end, Beacon tracks, investigates, and works to proactively address Potential Quality of Care Concerns. Please complete and submit the form below to inform Beacon of any Potential Quality of Care Concerns.

  • Referral Form
    Note: This form is not applicable to health plans based in AR, CT, GA, MA (if Medicaid), NH, PA, or WA. Please follow local notification processes.

Electroconvulsive Therapy (ECT) Forms

Repetitive Transcranial Magnetic Stimulation (rTMS) Form

Psychological Evaluation Forms

Treatment Coordination Forms

Treatment Record Review Forms

Guides and Resource Documents

Formulaires de traitement de l'analyse comportementale appliquée (ABA)