Provider Forms

MBHN Clinical Forms

• ABA Request for Treatment

• MBHN Case Closing Summary

• MBHN Initial Clinical Assessment (ICA)

• MBHN Outpatient Treatment Report (OTR)

• MBHN Request for Psychological Testing

• Medication Management Review

• Request for ECT Treatment

• Request for TMS Treatment

Claims/Billing Forms

• CMS1500 Billing Form

• Provider Request for Reconsideration

EAP Clinical Forms

• EAP Case Closing Summary

• EAP Case Closing FAQs

• EAP Statement of Understanding

• EAP Assess and Refer Model Assessment Form (La Porte County Government Only)

• Management Referral Information Guide for Therapists

• Management Referral Monthly Employee Progress Report from Therapist

• Provider Guide to Fitness for Duty and Risk Assessments

Utilization Management/Quality Improvement Forms

• Parity Utilization Review Reference Guideline

• Sample PCP Coordination of Care Letter
  Letter given to providers as a template for use in communicating with member's PCP regarding their behavioral health care treatment plan.

• Tool for Coordination of Care with PCP

• Utilization Management Procedures for Behavioral Health Benefits for Parity Compliant Programs

Provider Practice Changes

• Updating Provider Practice Information
  Return along with current malpractice insurance certificate and W9

• Re-Credentialing Practice Specialty Form