Forms, guides, and resources

Find all the forms, guides, tools, and other resources you need to support the day-to-day needs of your patients and office.*

Billing and claims

 

 Claims Based Dispute Resolution Request Form

 95-Day Waiver Request Form

 120-Day Waiver Request Form

 150-Day Waiver Request Medicaid Only

 365-Day Waiver Form

 Adjustment Void Request Form

 Claim Inquiry Form

 CMS 1500 Claim Form

 Inpatient Treatment Report Instructions

 Medicare Waiver of Liability Form

 Payment Integrity Provider Documentation Standards and Requirements

 Third-Party Liability Indicator

 Tips for Completing a CMS 1500

 Tips for Completing the UB04

 UB04

 W9

Change request

 

 Affidavit DEA Document

 Alternate Provider Roster Template

 Change of Address Packet

 Disclosure of Ownership Form

 Facility Address Change Form

 Facility Initial Application

 Facility Recred Application

 Facility Roster Form

 Group Addition Form

 Group Practice Roster

 Group Practice Tip Sheet

 Leave of Absence Out of Office Notification Form

 Locations and Services Form

 Roster for ABA Paraprofessional Providers

 Site Information Change Form

 

Clinical

 

 ABA Authorization Request Form

 ABA Treatment Report Guidelines

 Coordination of Care Authorization

 Esketamine-Spravato Request Form

 ECT Authorization Request Form

 Inpatient Treatment Report

 Member Coordination of Care Tip Sheet

 Outpatient Medication Management Registration Form

 Outpatient Treatment Report Form

 Psych Neuropsych Evaluation Request Form

 Reporting a Potential Quality of Care Concern Provider Form

 rTMS Authorization Request Form

Employee Assistance Program (EAP)

 

 Authorization to Disclose Health Information for Formal or Mandatory Referrals to the EAP

 Authorization to Disclose Health Information for Formal or Mandatory Referrals to the EAP (Spanish)

 Authorization to Disclose Health Information

 EAP Participant Statement of Understanding

 EAP Participant Statement of Understanding (Spanish)

 EAP Provider FAQ

 EAP Provider Handbook

 EAP Statement of Understanding - Formal or Mandatory Referrals

 EAP Statement of Understanding - Formal or Mandatory Referrals (Spanish)

 270 271 Companion Guide

 837 Health Care Claim Companion Guides

Questions? We're here to help.

Whether you have a question or are interested in learning more about how we can best support you, please call our National Provider Services Line at 800-397-1630, Monday to Friday, 8 a.m. to 8 p.m. Eastern time.

* Today we are Carelon Behavioral Health, but when some of these materials were developed, we were Beacon Health Options.