Behavioral Health Forms

Document Title Document Type Document Size Last Updated
Behavioral Health Forms
Ancillary Provider Credentialing Attestation Form PDF 300kb 12/08/2021
Applied Behavior Analysis (ABA) Initial Assessment Network Exception Request Form PDF 248kB 05/19/2023
Applied Behavior Analysis (ABA) Prior Authorization Form PDF 299kB 01/23/2024
Behavioral Appeals Cover Sheet PDF 233kB 09/01/2021
Behavioral Transition of Care / Continuity of Care Request Form PDF 130kB 02/02/2024
Coordination of Benefit PDF 17KB 08/01/2013
EAP Clinical Assessment Form PDF 358KB 08/27/2013
EAP Statement of Understanding PDF 2.44MB 04/01/2013
Employee Assistance Program (EAP) Assessment and Referral Specialty Opt-Out Form PDF 214kB 09/01/2021
Fast Access Network Form PDF 397kB 03/08/2022
HCFA/CMS 1500 Online Resource -- 02/03/2015
Health Care Professional Directory Changes Online Resource -- 04/07/2020
Informed Consent Form PDF 14KB 08/01/2013
Inpatient Prior Authorization Form PDF 252KB 04/10/2024
IOP Network Exception Request Form PDF 252KB 02/23/2023
Outpatient Behavioral Network Exception Request Form PDF 460kB 06/18/2024
Request-Refuse Interpretation Services – English (all states except CA) PDF 106 KB 03/17/2023
Request-Refuse Interpretation Services – English (all states except CA) – Readable PDF PDF 172 KB 03/17/2023
Request-Refuse Interpretation Services – Spanish (all states except CA) PDF 215 KB 03/17/2023
Self-Pay Agreement PDF 15KB 08/01/2013
Specialty Attested Form PDF 249kB 11/02/2022
Specialty Attestation for Participation* PDF 96KB 08/01/2013
Specialty Verified Form PDF 191kB 09/01/2021
Spravato Prior Authorization Form PDF 67kB 01/11/2022
Transcranial Magnetic Stimulation (TMS) Request Form PDF 340kB 07/27/2023
Treatment Record Review Tool PDF 157kB 09/01/2021
W-9 Form Online Resource -- 09/01/2021
Document Title Document Type Document Size Last Updated
State-Specific Forms
Arizona Prior Authorization Form PDF 303kB 08/24/2022
California – Request-Refuse Interpretation Services – English PDF 405 KB 09/13/2013
California – Request-Refuse Interpretation Services – Spanish PDF 24 KB 09/13/2013
California – Request-Refuse Interpretation Services – Chinese PDF 97 KB 09/13/2013
Florida Prior Authorization Form PDF 260kB 08/24/2022
Florida Prior Authorization Form – Instructions PDF 77kB 05/18/2022
Indiana Prior Authorization Form Online Resource -- 02/14/2024
Maryland Uniform Treatment Plan Form PDF 469 kB 02/06/2024
Massachusetts Prior Authorization Form PDF 540kB 02/14/2024
Massachusetts Prior Authorization Form - Transcranial Magnetic Stimulation Online Resource -- 02/07/2024
Massachusetts Psychological and Neuropsychological Assessment Supplemental Form PDF 247kB 01/23/2024
Massachusetts Standard Form for Applied Behavior Analysis Services Prior Authorization Requests PDF 539kB 04/02/2024
Nevada Uniform Prior Authorization Form PDF 885kB 11/30/2023
New Mexico Prior Authorization Form PDF 269kB 02/14/2024
Tennessee ABA Prior Authorization Form PDF 246kB 01/30/2024
Tennessee IOP Request Form PDF 226kB 12/29/2023
Tennessee Transcranial Magnetic Stimulation (TMS) Form PDF 257kB 01/30/2024
Texas Prior Authorization Form PDF 3.09MB 02/09/2024
Vermont Gold Carding Pilot Program PDF 123kB 03/17/2022
Vermont Medical Prior Authorization Form Online Resource -- 02/09/2024
Washington Next Day Appointment Referral Tool PDF 288kb 02/16/2023
West Virginia Prior Authorization Form Online Resource -- 01/11/2024
Document Title Document Type Document Size Last Updated
Letter Templates
Consent for Release of Confidential Information to Primary Care Physician PDF 16kB 07/28/2021
Draft Letter for Practitioners’ Communications with Primary Care Physicians PDF 65kB 09/01/2021

* The Massachusetts Department of Insurance also requires electronic access to the Psychological and Neuropsychological Assessment Supplemental Form, however, it is not provided because Evernorth does not require prior authorization for psychological and neuropsychological assessments.