Clinical Forms

Outpatient Treatment Report Forms

For most efficient and timely service – use of authorization request flow on ProviderConnect^SM 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.

• Outpatient Review
• Instructions
  Use for Outpatient Reviews
• Medication Management Registration Form
  Only use this form if you are credentialed to offer medication management services.
• New York State OASAS Notification of Admission for Inpatient and Residential Substance Use Disorder (SUD) Services
  Required for New York Medicaid, CHP, Essential, and Commercial plans.
• New York State OASAS Notification of Admissions for Outpatient Substance Use Disorder (SUD) Services
  Required for New York Medicaid, CHP, Essential, and Commercial plans.

Inpatient and Higher Levels of Care Authorization Requests

For most efficient and timely service — use of authorization request flow on ProviderConnect 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 ProviderConnect, our secure HIPAA-compliant provider application. Alternatively, you may contact us by dialing the toll-free number on the member’s 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 on-line. If you are unable to complete the request on-line, please contact customer service by dialing the toll-free number on the member’s 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.

• Inpatient Treatment Report
• Instructions
  Use for authorization requests for inpatient and all alternative/higher levels of care.

Electroconvulsive Therapy (ECT) Forms

• Request to Authorize ECT

Psychological Evaluation Forms

• Psychological/Neuropsychological Evaluation Request
• List of Psychological Tests

Treatment Coordination Forms

• Coordination of Care Authorization
• Member Coordination of Care Tip Sheet

Treatment Record Review Forms

• Standard Treatment Record Review
• Michigan Engagement Center Treatment Record Review

Guides and Resource Documents

• Impairment Scale and Risk Rating Guide

Applied Behavioral Analysis (ABA) Treatment Forms

• ABA Provider Treatment Report Guidelines
• ABA Authorization Request and Treatment Report — Initial
• ABA Authorization Request and Treatment Report — Concurrent