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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.

Forms

 Claims Based Dispute Resolution Request Form - California

 Claims Based Dispute Resolution Request Form - Florida

 Claims Based Dispute Resolution Request Form - Maryland

 Claims Based Dispute Resolution Request Form - Massachusetts

 Claims Based Dispute Resolution Request Form - New York

 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

 Affidavit DEA Document

 Amendment Request Form

 Change of Address Packet

 Disclosure of Ownership Form

 Leave of Absence Out of Office Notification Form

 Manual Attestation Form

 Practitioner Credentialing Application

 Provider Enrollment - Join an Existing Group

 Site Information Change Form

 ABA Authorization Request Form

 ABA Treatment Report Guidelines

 Access to Care Protocol

 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

 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)

Roster Automation*

Facility Forms ONLY
(Do not use for Provider Groups)

Other

*Currently in a pilot phase with eligible delegated Provider Groups; access will expand to additional groups and facilities soon—watch for updates. To confirm if you are part of the pilot phase, please contact your network manager. If submitted for roster automation without proper setup, there will be a failure in processing. 

Guides

GET READY FOR EASIER ROSTER SUBMISSIONS –
NEW AUTOMATION LAUNCHING FALL 2025

We’re making it easier for you to submit and manage your rosters – less hassle, fewer errors, and quicker updates. 

This fall, Carelon Behavioral Health will launch a new automated roster solution designed to simplify and centralize roster submissions, starting with provider groups. Facilities will be included in the rollout shortly thereafter. 

This upcoming enhancement will transform how we intake, process, and update provider data. By automating the intake of roster files, we’ll reduce the manual effort – ensuring faster, more accurate updates to our core systems. 

What this means for you: 

  • Enhanced communications: Automated email updates to keep you informed on progress 
  • Faster turnaround: Automation speeds up processing and integration 
  • Higher accuracy: Data errors and inconsistencies are minimized 
  • One centralized intake: A single, streamlined entry point for roster submissions 

How to prepare:

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.