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Behavioral Health Forms


Microsoft Word - 3265-1_Customer Advocate Unit Preauth_WNY_9-3-14.docx
This form is used to request prior authorization for services such as surgeries, therapies, or procedures.
3265-6_DME PreAuth_WNY (P)
Health Care Proxy Form
The New York Health Care Proxy Law allows you to appoint someone you trust to make health care decisions for you if you lose the ability to make decisions yourself.
Health Survey for Adolescents
A brief tool to help address high priority risk behaviors and allow for dialogue between the adolescent and their health care provider.
Health Survey for Adolescents Provider Information
Health Survey for Adolescents Provider Information
In-Network Referral Form
Fillable form for fax use.
Lead Risk Assessment
In addition to the state mandated required testing at ages one and two, assessment of risk for high-dose lead exposure should be done at least annually for each child six months to six years of age.
Medicaid Managed Care Only Home Assessment PCS
This form must be completed for Medicaid patients receiving personal care services or requesting personal care services.
OPA Registration Form for Selected Services
View Patient Registration
Microsoft Word - 3265-10_Out of Plan Referral Review Request_WNY_9-8-14.docx
This form is used to request an Out-of-Plan Referral also referred to as an Out-of-Network Referral, for services outside of the Servicing Network.
Preauthorization Request for BRCA Testing
This form is used to request prior authorization for breast cancer (BRCA) gene testing.,()
3265-8_HHC PreAuth_WNY (P)
Preconception Checklist
Prior Approval Non Formulary Request Form
This prior authorization is subject to all drug therapy guidelines in effect at the time of the approval and other terms, limitations and provisions in the member's contract/rider. We reserve the right to update and/or modify our drug therapy guidelines for prospective services.
Provider Office Accident Questionnaire
This form is used to assist in determining if a patient is eligible to receive Workers' Compensation, No-Fault Automobile or Personal Liability insurance benefits due to a possible accident or injury.
Updated Standard PA Form.pdf
Microsoft Word - 3265-1_CAU_Preauth_WNY.docx
Microsoft Word - 3265-6_DME_PreAuth_WNY.docx
Microsoft Word - 3265-8_HHC_PreAuth_WNY.docx
Microsoft Word - 3265-10_OON_PreAuth_WNY.docx


Reimbursement Forms

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