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
150-Day Waiver Request Medicaid Only
Inpatient Treatment Report Instructions
Medicare Waiver of Liability Form
Payment Integrity Provider Documentation Standards and Requirements
Third-Party Liability Indicator
ABA Authorization Request Form
ABA Treatment Report Guidelines
Coordination of Care Authorization
Esketamine-Spravato Request Form
ECT Authorization Request Form
Member Coordination of Care Tip Sheet
Outpatient Medication Management Registration Form
Outpatient Treatment Report Form
Psych Neuropsych Evaluation 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 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)
- Facility Address Change Form
- Facility Recred Application
- Facility Roster Form
- Locations and Services Form
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
SIMPLIFY YOUR ROSTER SUBMISSIONS WITH AUTOMATION
We’ve made it easier to submit and manage your rosters—reducing hassle, minimizing errors, and helping you keep provider information up to date.
Our automated roster solution is designed to simplify and centralize roster submissions, creating a more efficient and streamlined experience for provider groups and facilities*.
By automating the intake of roster files, we help reduce manual effort while supporting faster, more accurate updates to core systems.
What this means for you:
- Enhanced communications: Automated email updates keep you informed on submission status
- Faster turnaround: Automation supports quicker processing and integration
- Higher accuracy: Reduced data errors and inconsistencies
- Centralized intake: A single, streamlined entry point for roster submissions
Helpful resources:
- Participate in our provider training
- Review the Roster Automation Provider Tip Sheet
- Share this information with your roster management team to ensure alignment
- Use the Carelon Roster Automation Standard Template for submissions
* 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.
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.