Administrative

» Facility Address Change Form

» Individual Provider Address Change

» Intermediary Authorization

» Online Service Account Request

» W-9 Substitute

Claims

» Adjustment Form

» CMS 1500 Claim Form

» CMS 1500 Directions

» CMS 1500 Example of Claim

» UB04 Claim Form

» UB04 Claim Tip Sheet

Clinical

» Adult Uniform Assessment Form

» Child & Adolescent Uniform Assessment Form (Updated 11/07)

» Care First Form

» Brief Bipolar Disorder Symptom Scale (BDSS)

» Dimensions for Assessment and Rating System/Adult TRAG

» Individual Provider Outlier Form

» Instructions to OYPSS

» Ohio Youth Problem, Functioning and Satisfaction Scales

» Ohio Youth Problem, Functioning and Satisfaction Scales (Spanish)

» QIDS-SR

» Required Forms Instructions

» Supported Employment Authorization Request/Treatment Plan

» Uniform Assessment Attachment Form (New)

Eligibility

» Financial Assessment Tool - New

» Financial Assessment Tool (En Español) - New

» Financial Eligibility Checklist - New

» Financial Eligibility Checklist (En Español) - New

» Verification of Assistance Form - New

» Verification of Assistance Form (En Espanol) - New

Pharmacy

» PA/Medication Form

» Prescribing Provider Form

Quality

» Death Report Form

» TIMA Adult Order Forms (New)

» TIMA Children Order Forms (New)

Other

» UTMB Health Assessment Form (Revised)

» Exemption from Telemedicine Consultation Form