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New Avenues

Employee Assistance
About EAP
Work-Life Balance
Work-Life Resource Center
Provider Directory
Blog
Behavorial Health
About MBHN
Help for Depression
Services for Children With Autism Spectrum Disorder
Provider Directory
Blog
Providers
Provider Overview
Becoming A Provider
Provider Directory
Forms
Provider Networks
Reference Material
Blog
Provider Newsletter
Employers
Employer EAP
Employer MBHN
Specialized Business Solutions
Broker/Buyer
Our Company
About Us
People and Values
Careers
Blog
Services
Resources
Contact Us
Contact
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Forms for Providers

  • Providers
  • Provider Overview
  • Becoming A Provider
  • Provider Directory
  • Forms
  • Provider Networks
  • Reference Material
  • Blog
  • Provider Newsletter

Provider Forms

MBHN Clinical Forms

  • ABA Request for Treatment

  • MBHN Case Closing Summary

  • MBHN Initial Clinical Assessment (ICA)

  • MBHN Outpatient Treatment Report (OTR)

  • MBHN Request for Psychological Testing

  • Medication Management Review
    Medication Management Authorization Request

  • Request for ECT Treatment

Claims/Billing Forms

  • CMS1500 Billing Form

  • Provider Request for Reconsideration

EAP Clinical Forms

  • EAP Case Closing Summary

  • EAP Level I Assessment

  • EAP Statement of Understanding

  • Management Referral Information Guide for Therapists

  • Management Referral Monthly Employee Progress Report from Therapist

  • Provider Guide to Fitness for Duty and Risk Assessments

Utilization Management/Quality Improvement Forms

  • Parity Utilization Review Reference Guideline

  • Sample PCP Coordination of Care Letter
    Letter given to providers as a template for use in communicating with member's PCP regarding their behavioral health care treatment plan.

  • Tool for Coordination of Care with PCP

  • Utilization Management Procedures for Behavioral Health Benefits for Parity Compliant Programs

Provider Practice Changes

  • Updating Provider Practice Information
    Return along with current malpractice insurance certificate and W9

  • Re-Credentialing Practice Specialty Form

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New Avenues, Inc - P.O. Box 360 - South Bend, IN 46624
EAP: (574) 232-2131 or (800) 731-6501
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