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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
6

Medicare Assured® Drug Exception Form
7 Member Medicare Assured® Drug Exception Form
8 Home Infusion Drug Request Form
9 Pharmacy NCPDP Payer Sheet
10 Medicare Part D Coverage Determination Request Form
GENERAL PROVIDER FORMS
11 Appointment of Representative Form
12 Asthma and Cardiac Referral Fax Form
13

CMS UB-04 Form

14

CMS-1500 Form

15 Member Outreach Form
16 Notice of Discharge & Medicare Appeal Rights
17 Notice of Medicare Non-Coverage Form - Instructions
18

Obstetrical Needs Assessment Form

19 PCP On Call Coverage Arrangement Form
20 Practice Change Request Form
21 Waiver of Liability Statement Form
REFERENCE MATERIALS
22 Quick Reference Guide for Referrals and Authorizatons
23 NPI Billing Reference Guide

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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