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