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UPMC Health Plan Behavioral Health Services Provider Forms

All Providers

Initial Outpatient Request Form 191 KB 1 page PDF

Outpatient Treatment Plan 36 KB 1 page PDF

Psych Testing Precertification Request Form
31 KB 2 pages PDF

UPMC for Kids - Member Authorization to Use or Disclose Protected Health Information 55 KB 2 pages PDF

UPMC Health Plan/UPMC for Life - Member Authorization to Use or Disclose Protected Health Information 495 KB 3 pages PDF