Forms and References

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 Outcomes 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	Gateway Health Plan^® Tips
2	Model of Care
3	NPI Billing Reference Guide
4	Patient Question List
5	Quick Reference Guide for Referrals and Authorizatons

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.

Medicare Assured^® HMO
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Last Updated: 2/17/2010

Medicare Assured® HMO

Provider Forms & Reference Materials

Medicare Assured^® HMO