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Provider Forms & Reference Materials

BEHAVIORAL 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
1

Medicare Assured® Drug Exception Form
2 Member Medicare Assured® Drug Exception Form
3 Home Infusion Drug Request Form
4 Pharmacy NCPDP Payer Sheet
5 Medicare Part D Coverage Determination Request Form
6 Synagis Prescription and Prior Authorization Request Form
GENERAL PROVIDER FORMS
1 Appointment of Representative Form
2 Asthma and Cardiac Referral Fax Form
3

CMS UB-04 Form

4

CMS-1500 Form

5

Maternity Outomes Authorization Form
6 Member Outreach Form
7 Notice of Discharge & Medicare Appeal Rights
8 Notice of Medicare Non-Coverage Form - Instructions
9

Obstetrical Needs Assessment Form

10 PCP On Call Coverage Arrangement Form
11 Practice Change Request Form
12 Waiver of Liability Statement Form
13 Refund Form
REFERENCE MATERIALS
1 Quick Reference Guide for Referrals and Authorizatons
2 NPI Billing Reference Guide
3 Gateway Health Plan® Tips
4 Patient Question List

Forms require the Adobe Acrobat Reader installed on your system. Most computers have this program installed. If it is not installed on your computer, you can download it for free from Adobe.

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