Clinical Forms
Outpatient Treatment Report Forms
- Outpatient Registration Form (ORF1) (PDF)
- Instructions (PDF)
- Outpatient Review Form (ORF2) (PDF)
- Instructions (PDF)
- Medication Management Registration Form (PDF)
- Outpatient Discharge Form (PDF)
- Adjustment Disorder Review Form (DOC)
- Adjustment Disorder Review Form Instructions (PDF)
Use for routine outpatient.
A companion form to the ORF1, only use the ORF2 if requested to do so.
Only use this form if you are a ValueOptions provider credentialed to offer medication management services.
Inpatient and Higher Levels of Care Authorization Requests
- Inpatient Treatment Report (PDF)
- Instructions (PDF)
- Medication Management Registration Form (PDF)
Use for authorization requests for inpatient and all alternative/higher levels of care.
Psychological Evaluation Forms
- Psychological/Neuropsychological Evaluation Request (PDF)
- List of Psychological Tests (PDF)
- NC Medicaid Psychological Testing Form (PDF)
Treatment Coordination Forms
- Primary Care Physician Coordination Form (PDF)
- Coordination of Care Authorization (PDF)
- Member Coordination of Care Tip Sheet (PDF)