New Avenues Provider Forms
- Consent to Pay for Non-Covered Services -
- EAP Case Closing Summary -
- EAP Gatekeeping Outpatient Treatment Report -
- EAP Level I Assessment -
- EAP Level II Assessment -
- EAP Request for Psychological Testing -
- EAP Statement of Understanding -
- Form CMS-1500 - Outpatient claim form
- Form UB-92 (HCFA 1450) - Billing form for hospital outpatient and inpatient claims.
- Guidelines to Use of AXIS V: Global Assessment Functioning Scale -
- Management Referral Information Guide for Therapists -
- Management Referral Monthly Employee Progress Rpt from Therapist -
- MBHN Case Closing Summary -
- MBHN Initial Clinical Assessment (ICA) -
- MBHN Medication Management Review -
- MBHN Outpatient Treatment Report (OTR) -
- MBHN Request for Psychological Testing -
- PCP Coordination of Care - Sample Letter - Sample letter for Provider Communication with PCP
- Provider Guide to Fitness for Duty and Risk Assessments -
- Provider Information Update Form -
- Provider Manual - Behavioral Health Section -
- Provider Manual - Claims Section -
- Provider Manual - Employee Assistance Program Section -
- Provider Manual - Introduction Section -
- Provider Manual - Provider Relations Section -
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