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 

2019 Psychology and Neuropsychology Testing and Evaluation Service Codes FAQ 

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 

Psychological Neuropsychological Testing Update 

Third-Party Liability Indicator 

Tips for Completing a CMS 1500 

Tips for Completing the UB04 

UB04 

W9 

Change request

 

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 2019 CPT Codes 

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 

Treatment Record Review Audit Tool 

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 

CAF-1 EAP Case Activity and Billing Form 

CAF-2 EAP Case Activity and Billing Form 

EAP Case Activity and Billing Form FAQ 

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) 

Important EAP Case Activity and Billing Form Information 

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.

Questions? We're here to help.

Whether you have questions or are interested in learning more about how we can best support you, please reach us by calling our National Provider Services Line at 800-397-1630, Monday through 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.