Forms and References

Medicare Assured^® > Ohio > Providers > Forms and References

Providers Enroll as a Provider Members Ohio Medicare Assured^® Contact Us

BEHAVIORIAL HEALTH FORMS - these forms can be downloaded from http://www.cbhnp.org/gateprovforms.aspx
1	Outpatient Treatment Registration Form For Mental Health Services
2	Outpatient Treatment Registration Form For Substance Abuse
3	Request for Neuropsychological Evaluation
4	Request for Authorization of Psychological Testing
5	Mental Health & Substance Abuse Outpatient Form Instructions
PHARMACY FORMS
6	Medicare Assured^® Drug Exception Form
7	Smoking Cessation Form
8	Member Medicare Assured^® Drug Exception Form
9	Home Infusion Drug Request Form
10	Pharmacy NCPDP Payer Sheet
11	Medicare Part D Coverage Determination Request Form
GENERAL PROVIDER FORMS
12	Appointment of Representative Form
13	Asthma and Cardiac Referral Fax Form
14	CMS UB-04 Form
15	CMS-1500 Form
16	Member Outreach Form
17	Notice of Discharge & Medicare Appeal Rights
18	Notice of Medicare Non-Coverage Form - Instructions
19	Obstetrical Needs Assessment Form
20	PCP On Call Coverage Arrangement Form
21	Practice Change Request Form
22	Waiver of Liability Statement Form
REFERENCE MATERIALS
23	Quick Reference Guide for Referrals and Authorizatons
24	NPI Billing Reference Guide

Drug Safety Information

Drug Recall

Gateway at a Glance

Provider News

Manual

Forms and References

Authorization Guide

Adjustment Code

Newsletters

Behavioral Health

Clinical Guidelines

Complex Case Management

Medical Directors

Last Updated: 10/28/2008