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HealthChoices Forms


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Choose one or more contracts to see the forms specific to that contract, and click 'Show Forms'.
Allegheny Chester North Central
Blair Erie North East
Carbon/Monroe/Pike Lycoming-Clinton York/Adams, Berks
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Behavioral Health Rehabilitation Services (BHRS)
BHRS are treatment and therapeutic interventions prescribed by a psychologist or psychiatrist provided on an individual basis in the person's own environment such as the home, school and community. These services include Therapeutic Support Staff (TSS), Behavioral Specialist Consultants (BSC), Mobile Therapy (MT) and specialized services, as approved.

When submitting a packet, 6 items are required: the Best Practices Evaluation, the Individual Treatment Plan, and the 4 forms that are labeled *required for packet submission below.
Evaluation Authorization Request
TSS Schedule Forms (All Counties)
Sample TSS Schedule Form | TSS Schedule Form and Directions | TSS Schedule Form Training | Final TSS Schedule Form (*required for packet submission)
Life Domain BP Format for Evaluations
All Counties
Guidelines for Addendums to Evaluations
All Counties
ISPT Meeting Invitation
All Counties
Prescriber Responsibilities at ISPT
All Counties
BHRS Plan of Care Form and Directions
(*required for packet submission)
MST and FFT Plan of Care Form and Directions
(*required for packet submission when submitting MST and FFT Packet)
ISPT Sign In, Confidentiality Statement, Summary and Prescriber Collaboration
All Counties (*required for packet submission)
Family Choice Notification
(*required for packet submission)
Discharge Checklist and Summary
All Counties
FBA Certification Update
All Counties
BHRS Planning Guide
English Version | Spanish Version
Summer Therapeutic Activities Programs (STAP) Documents
Procedures/Q&A | Registration Form

Drug & Alcohol (D&A) Services
 
D&A Precertification Template
All Counties
D&A Continued Stay Review Template
All Counties
D&A Discharge Template
All Counties

Partial and Intensive Outpatient Services
 
Substance Abuse Partial/IOP Notification
All Counties
Mental Health Partial Program Notification: Adult
All Counties
Mental Health Partial Program Notification: Child/Adolescent

Family Based Mental Health Services (FBMHS)
FBMHS are evaluation and treatment services provided to a specific child in a family, but focuses on strengthening the whole family system to increase their ability to successfully manage their child's behavioral and emotional issues. Services are provided by licensed agencies employing a mental health professional and a mental health worker as a team to provide treatment and case management interventions. Services are provided in the home of the family.
Precertification
All Counties
Best Practice Prescription Letter
All Counties

Residential Treatment Facility (RTF)
RTF services are comprehensive mental health treatment services for children with severe disturbances or mental illness. These services are provided in Residential Treatment Facilities (RTF's) which must be licensed by OCY&F under Chapter 3800. The facility must have a service description approved by OMHSAS, be certified by OMHSAS through annual on-site review, have a utilization review plan in effect and be enrolled in the MA program.
Life Domain BP Format for Evaluations
All Counties
Guidelines for Addendums to Evaluations
All Counties
Plan of Care Form and Directions
All Counties
ISPT Invitation Form
All Counties
ISPT Sign In Sheet
All Counties
ISPT Summary
All Counties
Family Choice Notification
Attachment 8
All Counties
Discharge Summary
All Counties
Admission-Discharge Notification
All Counties

Other Services
 
Case Management Discharge Notification Form
All Counties
Neuro/Psychological Testing Preauthorization Request
All Counties
Mental Health Precertification Template - Adult
All Counties
Mental Health Precertification Template - Child
All Counties
Mental Health Continued Stay Review Template
All Counties
Mental Health Discharge Template
All Counties
Inpatient Mental Health Medical Necessity Criteria
All Counties
Peer Support Services Request Form
All Counties
Prescribing Practitioner Reporting
All Counties
Specialized Services Continued Stay Review
All Counties

Release of Information Forms
 
All County ROI's
PH BH Common Consent Form and Addendum A & B 323 KB 8 pages PDF
PH BH Common Consent Form and Addendum A & B (espanol) 133 KB 8 pages PDF
Authorization for Release of Information 22 KB 1 page PDF
Authorization for Release of HIV Information 15 KB 1 page PDF

Coordination of Benefits
 
Coordination of Benefits Discharge Review
All Counties 500 KB 1 page PDF

Unusual Incidents
 
Unusual Incident Report Form
All Counties 472 KB 2 pages PDF

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