Forms and References

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

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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Last Updated: 7/9/2010

Medicare Assured® HMO

Provider Forms & Reference Materials

Medicare Assured^® HMO