Behavioral health authorization forms

Out of network providers request mental health and substance use disorder services using the following forms:

• General behavioral health authorization form
  Use this form for: psychiatric inpatient, outpatient psychotherapy (mental health and substance abuse), detoxification, residential treatment and other behavioral health services
• Applied Behavioral Analysis (ABA) therapy authorization request form
• Transcranial Magnetic Stimulation (TMS) for depression authorization request form

Other behavioral health forms

• Behavioral health/Midlevel practitioner enrollment form
  Require supplement to the CAQH online application for behavioral health provider credentialing
• Coordination of Care with PCP form
  Use to provide information to the members PCP and other specialists