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HealthChoices Forms
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Community Care recently held a training regarding how to fill out the TSS Schedule Form and new ISPT Summary Form. To view this training, click here.
| 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. |
| Extended Assessment Authorization Request Form |
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Chester |
| Authorization Request for TPL Exempt Intake Assessment & Life Domain Evaluation |
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Chester |
| Transition Form and Directions |
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Carbon/Monroe/Pike |
| Evaluation Authorization Request |
| Allegheny |
Carbon/Monroe/Pike | Chester | North Central | North East | York/Adams, Berks |
| TSS Schedule Forms (All Counties) |
| Sample TSS Schedule Form | TSS Schedule Form and Directions | Final TSS Schedule Form (*required for packet submission) |
| Life Domain Format for Evaluations |
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All Counties |
| Prescriber Responsibilities if Using Assistants for Evaluations |
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All Counties |
| Guidelines for Addendums to Evaluations |
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All Counties |
| ISPT Meeting Invitation |
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All Counties |
| Prescriber Responsibilities at ISPT |
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All Counties |
| BHRS Plan of Care Form and Directions |
| Allegheny |
Carbon/Monroe/Pike | Chester | North Central | North East | York/Adams, Berks (*required for packet submission) |
| Multisystemic Therapy (MST) Plan of Care Form and Directions |
| All Counties (*required for packet submission when submitting MST Packet) |
| ISPT Sign In, Confidentiality Statement, Summary and Prescriber Collaboration |
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All Counties (*required for packet submission) |
| Family Choice Notification |
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All Counties (*required for packet submission) |
| Discharge Checklist and Summary |
| All Counties |
| FBA Certification Update |
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All Counties |
| 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.
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| Transition of Care |
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Carbon/Monroe/Pike |
| Precertification |
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All Counties |
| Best Practice Prescription Letter |
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All Counties |
| Authorization Process |
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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.
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| Transition Form and Directions |
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Carbon/Monroe/Pike |
| Life Domain Format for Evaluations |
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All Counties |
| Guidelines for Addendums to Evaluations |
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All Counties |
| Plan of Care Form and Directions |
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All Counties |
| ISPT Sign In Sheet |
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All Counties |
| ISPT Summary |
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All Counties |
| Family Choice Notification |
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All Counties |
| Attachment 8 |
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All Counties |
| Discharge Summary |
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All Counties |
| Admission-Discharge Notification |
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All Counties |
| ALDA |
| Allegheny County Drug & Alcohol forms |
| Outpatient Notification -
AC Drug & Alcohol Services
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| Allegheny |
| Coordination of Benefits |
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| Coordination of Benefits Discharge Review |
| All Counties |
129 KB |
1 page |
PDF |
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