New Avenues Provider Forms
Forms
EAP Clinical Forms
- EAP Level I Assessment
- EAP Level II Assessment
- EAP Case Closing Summary
- EAP Statement of Understanding
- Management Referral Information Guide for Therapists
- Management Referral Monthly Employee Progress Rpt from Therapist
- Provider Guide to Fitness for Duty and Risk Assessments
MBHN Clinical Forms
Claims/Billing
- Form CMS-1500 - Outpatient claim form
- Form UB-92 (HCFA 1450) - Billing form for hospital outpatient and inpatient claims.
- Provider Request for Reconsideration - Claims
Provider Contracting/Manual
- Business Associate Agreement
- Consent to Pay for Non-Covered Services
- 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
Utilization Management/Quality Improvement
- Guidelines to Use of AXIS V: Global Assessment Functioning Scale
- PCP Coordination of Care - Provider Cover Letter
- PCP Coordination of Care - Provider Tool of Instructions
- PCP Coordination of Care - Sample Letter - Sample letter for Provider Communication with PCP
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