| Behavioral Treatment Record Review Tool |
PDF |
233KB |
12/08/2021 |
| Coordination of Benefits |
PDF |
17KB |
09/01/2021 |
| EAP Clinical Assessment Form |
PDF |
358KB |
09/01/2021 |
| EAP Statement of Understanding |
PDF |
119KB |
09/01/2021 |
| Employee Assistance Program (EAP) and Confide Assessment and Referral Specialty Opt-Out Form |
PDF |
214KB |
09/01/2021 |
| Electronic Payment and Remittance Reports |
Online Resource |
-- |
09/01/2021 |
| HCFA/CMS 1500 |
Online Resource |
-- |
09/01/2021 |
| Informed Consent Form |
PDF |
14KB |
09/01/2021 |
| Intensive Outpatient Program (IOP) Request Form |
PDF |
237KB |
09/01/2021 |
| Member Release of Information Form |
PDF |
96KB |
09/01/2021 |
| Provider Self-Introduction Form |
PDF |
232KB |
04/14/2023 |
| Self-Pay Agreement |
PDF |
15KB |
09/01/2021 |
| Specialty Attested Form |
PDF |
244KB |
09/01/2021 |
| Specialty Attestation for Participation |
PDF |
189KB |
09/01/2021 |
| Specialty Verified Form |
PDF |
191kB |
09/01/2021 |
| Termination Form (Individually Contracted Providers) |
PDF |
181KB |
09/01/2021 |
| W-9 Form |
PDF |
54KB |
09/01/2021 |