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Behavioral Health Forms

Additional Clinical Information
This form is used to provide additional behavioral health clinical information with respect to Timothy's Law benefits.
Autism Spectrum Disorder
Comprehensive Evaluation Request Form
Behavioral Health Practitioner Questionnaire
Behavioral Health Preauthorization Requirements
Preauthorization requirements for outpatient mental health and substance abuse services for self-funded/ASO & FEP members.
Biologically Based Mental Health Diagnoses Codes
The correct administration of this benefit requires accurate diagnosis coding and appropriate supporting documentation in the medical record. These are the Biologically Based Mental Health Diagnoses for Timothy's Law.
Chemical Dependency Outpatient Treatment Review (OTR) Form
Fax: 1-866-390-0864 | Service 1-877-837-0814
Mental Health Outpatient Treatment Review (OTR) Form
Fax 1-866-390-0864 | Service 1-877-837-0814
Outpatient Applied Behavioral Analysis Treatment Report
Preauthorization Grid
Preauthorization requirements for Outpatient Mental Health and Substance Abuse Services for Self-funded/ASO & FEP Members.
On December 22, 2006, New York State legislation known as “Timothy’s Law” was signed into law. This form is used to preauthorize the Initial 10 Visits.
Timothy’s Law Member Copayment/Coinsurance Request Form
This form allows you to request information for up to 8 members. Complete the left side of the form using the member’s name and identification number. Upon receipt, our staff will look up the requested members.
Microsoft Word - 8550-B_Accessing ASD Services_PROVIDER_WNY.doc

PATIENT CARE FORMS

Customer Advocate Unit Preauthorization Form
This form is used to request prior authorization for services such as surgeries, therapies, or procedures.
Durable Medical Equipment Preauthorization Form
This form is used to request a Prior Authorization for Durable Medical Equipment (DME)
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.
Medical Policy Inquiry Web E-mail Form
Complete the following form to request a review of our current position regarding a specific medical treatment or technology.
Medical Policy Inquiry Web Fax Form
Complete the following form to request a review of our current position regarding a specific medical treatment or technology.
NYS Medicaid Prior Authorization Form for Prescriptions
This form must be completed by physicians who are ordering personal care services for Medicaid patients.
OPA Registration Form for Selected Services
View Patient Registration
Out of Plan Case Review Request
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.
Preauthorization Request for Home Health Care Services
This form is used to request Prior Authorization for Home Health Care Services (Skilled Nursing visits, Home PT, OT, ST, HHA)
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 for webposting 122713.pdf

PRACTICE ADMINISTRATION

Reimbursement Forms

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