Forms
Download commonly used provider forms.
Download commonly used provider forms.
Employee Assistance Program (EAP) Provider Experience Summary
(96 KB) Download PDF
Please note that all billing address changes need to be submitted with a current W9
Address Change Form for All Providers (Except California)
(66 KB) Download PDF
English (link opens in new window)
Address Change Form for California Providers
(66 KB) Download PDF
Discharge Summary Form for All Providers (Except California)
(52.7 KB) Download PDF
English (link opens in new window)
Discharge Summary Form for California Providers
(52.7 KB) Download PDF
Coordination of Care Form for All Providers (Except California)
(197 KB) Download PDF
English (link opens in new window)
Coordination of Care Form for California Providers
(103 KB) Download PDF
Coordination of Care Instructions for All Providers (Except California)
(156 KB) Download PDF
English (link opens in new window)
Coordination of Care Instructions for California Providers
(672 KB) Download PDF
Outpatient Extended Care Form for All Providers (Except California)
(40 KB) Download PDF
English (link opens in new window)
Outpatient Extended Care Form for California Providers
(40 KB) Download PDF
English (link opens in new window)
(This form is to be used in conjunction with the Concurrent Clinical Review form in lieu of conducting a phone review with a clinical adviser.)
Neuro Psychological Testing Form for All Providers (Except California)
(49 KB) Download PDF
English (link opens in new window)
Neuro Psychological Testing Form for California Providers
(49 KB) Download PDF
Request for Psychology Testing Form for All Providers (Except California)
(49 KB) Download PDF
English (link opens in new window)
Request for Psychology Testing Form for California Providers
(49 KB) Download PDF
Florida Prior Authorization Form for Medical Procedures, Courses of Treatment or Prescription Drug Benefits (OIR-B2-2180)
(48 KB) Download PDF
2014 Practitioner Satisfaction Survey
(49 KB) Download PDF
English (link opens in new window)
2014 Practitioner Satisfaction Survey (California only)
(49 KB) Download PDF