Prior authorization
PHYSICAL HEALTH
- Physical health standard prior authorization request form (PDF)
- Outpatient Medicaid prior authorization and referral form (PDF)
- Gender-affirming services prior-authorization form (PDF)
BEHAVIORAL HEALTH
For behavioral health inpatient admissions fax clinical information to 844-528-3453 or call 866-329-4701 and follow prompts for inpatient BH admission
- Outpatient treatment request form (PDF)
- Intensive outpatient services request mental health & chemical dependency (PDF)
- Electroconvulsive therapy (PDF)
- Neuropsychological testing prior auth (PDF)
- Psychological testing prior auth (PDF)
- Mobile crisis notification (PDF)
- Intensive in-home services notification (PDF)
Other forms
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