Children's Mental Health Provider Forms

Appeal Forms

• Provider Administrative Review Request Form
• Claimant Fair Hearing Request Form

Acute Hospital

• Out of State Acute Inpatient Hospital Prior Authorization Request Form

Youth Genetics Testing for Mental Health

• Youth Genetics Testing for Mental Health Request Form

Partial Hospital Program

• Partial Hospital Program Initial Stay Request Form effective July 1, 2018
• Partial Hospital Program Continued Stay Request Form effective July 1, 2018

Psychiatric Residential Treatment Facilities (PRTF/PRTF-AS)

• Therapeutic Home Visit Over Three Days Request
• 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

Magellan Medicaid Administration Forms for Psychiatric Residential Treatment Facilities

• Correction to Youth Information Form
• Prior Authorization Request Form (PRTF)
• Continued Stay Authorization Request Form (PRTF)
• Discharge Notification (Magellan) Form
• Certificate of Need for Psychiatric Residential Treatment Facility

Integrated Co-Occurring Treatment (ICT)

• ICT Prior Authorization Request

Therapeutic Group Home

• Therapeutic Group Home Continued Stay Request Updated November 2017
• Extraordinary Needs Aid (ENA) Request For Youth in TGH 
• Discharge Notification Form TGH/HSS
• Therapeutic Home Visit Over Three Days Request
• Therapeutic Group Home Initial Stay Request Updated November 2017
• Emergency 72 hr TGH Payment Authorization Request
• Therapeutic Group Home Transfer Form Updated November 2017

Home Support Services

• Home Support Services Authorization Request After 365 Days of HSS Services Updated November 2017
• Home Support Services Exception to HSS Admission Criteria Request Updated November 2017
• Discharge Notification Form TGH/HSS

Non-Medicaid Services Forms

• Non-Medicaid Services including Room and Board Application and Attestation effective 10/14/2017