Forms

Download commonly used provider forms.

Employee Assistance Program Forms

Employee Assistance Program (EAP) Provider Experience Summary

(96 KB) Download PDF

English (link opens in new window) 

Provider Address Change Requests

Please note that all billing address changes need to be submitted with a current W9

Address Change Form for All Providers (Except CA)

(66 KB) Download PDF

English (link opens in new window) 

Address Change Form for California Providers

(66 KB) Download PDF

English (link opens in new window) 

Utilization Management

Discharge Summary Form for All Providers (Except CA)

(52.7 KB) Download PDF

English (link opens in new window) 

Discharge Summary Form for California Providers

(52.7 KB) Download PDF

English (link opens in new window) 

Coordination of Care

Coordination of Care Form

Coordination of Care Form for All Providers (Except CA)

(197 KB) Download PDF

English (link opens in new window) 

Coordination of Care Form for California Providers

(103 KB) Download PDF

English (link opens in new window) 

Coordination of Care Instructions

Coordination of Care Instructions for All Providers (Except CA)

(156 KB) Download PDF

English (link opens in new window) 

Coordination of Care Instructions for California Providers

(672 KB) Download PDF

English (link opens in new window) 

Outpatient Therapy

Outpatient Extended Care Form

Outpatient Extended Care Form for All Providers (Except CA)

(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/Psych Testing

Neuro Psychological Testing Form

Neuro Psychological Testing Form for All Providers (Except CA)

(49 KB) Download PDF

English (link opens in new window) 

Neuro Psychological Testing Form for California Providers

(49 KB) Download PDF

English (link opens in new window) 

Request for Psychology Testing Form

Request for Psychology Testing Form for All Providers (Except CA)

(49 KB) Download PDF

English (link opens in new window) 

Request for Psychology Testing Form for California Providers

(49 KB) Download PDF

English (link opens in new window) 

Practitioner Satisfaction Survey Tool

2014 Practitioner Satisfaction Survey

(49 KB) Download PDF

English (link opens in new window) 

2014 Practitioner Satisfaction Survey (CA only)

(49 KB) Download PDF

English (link opens in new window)