Medical authorization and other forms

Medical authorization forms

• Behavioral health prior authorization request form (PDF)
• Behavioral health substance use disorder (SUD) prior authorization form (PDF)
• Medical prior authorization form (PDF)
  Use this form for all medical-related prior authorization requests.
• OB authorization/notification form (PDF)

Other forms

• Behavioral health discharge note (PDF)
• Behavioral health fax form (PDF)
• Code of ethics and conduct certification and conflicts of interest disclosure (PDF)
• Discharge planning form (PDF)
• Discharge planning quick reference sheet (PDF)
• Electronic funds transfer authorization agreement - Dental (PDF)
• Level of (transportation) need assessment form (PDF)
• Enrollee PCP designation form (PDF)
• Enrollee reward fax request form (PDF)
• Non-participating provider form (PDF)
• PCP maximum capacity notice form (PDF)
• Prescriber/practitioner addition to formulary request form (PDF)
• Provider change form (PDF)
• Provider data intake form (PDF)
• Psychiatric residential treatment facility referral form (PDF)
• School-based dental sealant program referral form (PDF)
• Substance use discharge note (PDF)
• Transportation request form (PDF)