Children's Mental Health Provider Forms

Effective January 1, 2020, in partnership with Telligen, Mountain-Pacific will provide the utilization and review of behavioral health services provided by Children's Mental Health.  Please check out the Mountain Pacific Quality Health Website for forms, education, training and contact information.

Comprehensive School and Community Treatment

• CSCT Team Composition Prior Authorization Form

Home Support Services

• Discharge Notification Form TGH/HSS

Integrated Co-Occurring Treatment (ICT)

• ICT Prior Authorization Request

Mountain Pacific Quality Health Forms for Psychiatric Residential Treatment Facilities

• Youth Prior Authorization Request Form Psychiatric Residential Treatment Facility (PRTF)
• Youth Continued Stay Authorization Request Form Psychiatric Residential Treatment Facility (PRTF)
• Youth Discharge from Services Notification Form
• Youth Certificate of Need for Psychiatric Residential Treatment Facility (PRTF)

Non-Medicaid Services Forms

• Non-Medicaid Services including Room and Board Application and Attestation

Psychiatric Residential Treatment Facilities (PRTF/PRTF-AS)

• Interstate Compact Financial/Medical Plan
• ICPC 100A - Interstate Compact on the Placement of Children Request
• ICPC 100B - Interstate Compact on the Placement of Children Report on Child's Placement Status
• Report of Serious Occurrence

Serious Emotional Disturbance (SED) Diagnosis

• Montana Scale for Children/Adolescents with Serious Emotional Disturbance (SED) Checklist

Therapeutic Group Home

• Discharge Notification Form TGH/HSS
• Emergency 72 hr TGH Payment Authorization Request
• Therapeutic Group Home Transfer Form