Clinical Forms
Outpatient Treatment Report Forms
For most efficient and timely service – use of authorization request flow on ProviderConnect® is the preferred method of submitting requests. Faxed or mailed forms should only be submitted to the specific fax or address. Please confirm for a specific contract that forms are allowed. Some contracts allow only telephonic review if web service is not utilized. Some contracts require that requests only be submitted via the web.
- Outpatient Review 2013 (PDF)
- Instructions (PDF)
- Medication Management Registration Form 2013 (PDF)
Inpatient and Higher Levels of Care Authorization Requests
For most efficient and timely service – use of authorization request flow on ProviderConnect® is the preferred method of submitting requests. Faxed or mailed forms should only be submitted to the specific fax or address. Please confirm for a specific contract that forms are allowed. Some contracts allow only telephonic review if web service is not utilized. Some contracts require that requests only be submitted via the web.
- Inpatient Treatment Report (PDF)
- Instructions (PDF)
Psychological Evaluation Forms
- Psychological/Neuropsychological Evaluation Request (PDF)
- List of Psychological Tests (PDF)
- NC Medicaid Psychological Testing Form
Treatment Coordination Forms
- Primary Care Physician Coordination Form (PDF)
- Coordination of Care Authorization (PDF)
- Member Coordination of Care Tip Sheet (PDF)
