Forms

• 3M AmeriHealth Caritas User Acess Request Form Opens a new window (PDF)
• 3M Dashboard Step-by-Step User Guide Opens a new window (PDF) 
• ACT outcomes reporting form with instructions Opens a new window (PDF)
• Adverse incident reporting form Opens a new window (PDF)
• Adult and geriatric community-based treatment guidelines Opens a new window (PDF)
• Applied behavioral analysis (ABA) treatment request for a functional assessment form Opens a new window (PDF)
• Applied behavioral analysis (ABA) treatment request form Opens a new window (PDF)
• Authorization fax request form Opens a new window (PDF)
• Behavioral health adult assessment Opens a new window (PDF)
• Behavioral health adult mental health rehabilitation treatment request form Opens a new window (PDF)
• Behavioral health attestation for specialized provider requirement(s) Opens a new window (PDF)
• Behavioral health child and adolescent mental health rehabilitation treatment request form Opens a new window (PDF)
• Behavioral health certificate of need for psychiatric hospitalization or psychiatric residential treatment facility (PRTF) Opens a new window (PDF)
• Behavioral health discharge note Opens a new window (PDF)
• Behavioral health medical screening form Opens a new window (PDF)
• Behavioral health outpatient treatment request (OTR) form Opens a new window (PDF)
• Behavioral health progress note template Opens a new window (PDF)
• Behavioral health provider enrollment form Opens a new window (PDF)
• Behavioral health psychiatric residential treatment facility referral form Opens a new window (PDF)
• Behavioral health psychological/neuropsychological testing request form Opens a new window (PDF)
• Behavioral health treatment plan template Opens a new window (PDF)
• Certification of ambulance transportation form Opens a new window (PDF)
• Community brief crisis support request form Opens a new window (PDF)
• Consent for abortion Opens a new window (PDF)
• Consent for hysterectomy Opens a new window (PDF)
• Consent for sterilization Opens a new window (PDF)
• Consent for sterilization (Spanish) Opens a new window (PDF)
• Contract request form Opens a new window (PDF)
• Crisis intervention follow-up request Opens a new window (PDF)
• Department of Health and Hospitals newborn eligibility system user manual Opens a new window (PDF)
• Electric breast pump request form Opens a new window (PDF)
• EPSDT personal care services Opens a new window (PDF)
• Health and wellness questionnaire Opens a new window (PDF)
• Hospice certificate of terminal illness Opens a new window (PDF)
• Hospice notice of election Opens a new window (PDF)
• Hospice notice of election concurrent care Opens a new window (PDF)
• Hospital notification of emergency/urgent admission Opens a new window (PDF)
• Independent review provider reconsideration form Opens a new window (PDF)
• Infant/child referral for WIC certification and information transfer form Opens a new window (PDF)
• Initial crisis intervention notification request Opens a new window (PDF)
• Let Us Know - Member intervention request form Opens a new window (PDF)
• Let Us Know - Member intervention request form (Spanish) Opens a new window (PDF)
  
• Louisiana Uniform Prescription Drug PA request form Opens a new window (PDF)
  
• Medicaid program acknowledgement of receipt of hysterectomy information Opens a new window (PDF)
• Member's choice in provider Opens a new window (PDF)
• Multiple claims project sheet Opens a new window (PDF)
• National Quality Forum serious reportable events in health care Opens a new window (PDF)
• Non-participating provider emergency services payment guidance Opens a new window (PDF)
• Notification of pregnancy Opens a new window (PDF)
• Optum referral form Opens a new window (PDF)
• Patient consent for provider to file appeal form Opens a new window (PDF)
• Patient health questionnaire (PHQ-9) Opens a new window (PDF)
• Patient health questionnaire for adolescents (PHQ-A) Opens a new window (PDF)
• Patient stress questionnaire Opens a new window (PDF)
• Primary Care Provider (PCP) Selection Form Opens a new window (PDF)
• Provider change form Opens a new window (PDF)
• Provider dispute form Opens a new window (PDF)
• Provider enrollment form Opens a new window (PDF)
• Psychiatric Residential Treatment Facility (PRTF) Authorization Request Form Opens a new window (PDF)
• Substance abuse discharge note Opens a new window (PDF)
• TeleECHO™ Clinic Case Presentation Form Opens a new window (PDF)
• Wait and See Period Attestation Form (PDF) Opens a new window