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EAP Forms
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Outpatient Treatment Report Forms
Outpatient Registration Form (ORF1)
(PDF)
Instructions
(PDF)
- Use for routine outpatient.
Outpatient Review Form (ORF2)
(PDF)
Instructions
(PDF)
- A companion form to the ORF1, only use the ORF2 if requested by a ValueOptions Clinical Care Manager.
Medication Management Registration Form
(PDF)
- Only use this form if you are a ValueOptions provider credentialed to offer medication management services.
Outpatient Discharge Form
(PDF)
Inpatient and Higher Levels of Care Authorization Requests
Inpatient Treatment Report
(PDF)
Instructions
(PDF)
- Use for authorization requests for inpatient and all alternative/higher levels of care.
Medication Management Registration Form
(PDF)
Psychological Evaluation Forms
Psychological/Neuropsychological Evaluation Request
(PDF)
List of Psychological Tests
(PDF)
NC Medicaid Psychological Testing Form
(PDF)
Treatment Coordination Forms
Behavioral Healthcare Coordination Form
(PDF)
Member Coordination of Care Tip Sheet
(PDF)
Treatment Record Review Forms
Standard Treatment Record Review
(PDF)
Northeast and Empire Service Center Treatment Record Review
(PDF)
Great Lakes Service Center Treatment Record Review
(PDF)
