Forms

• 3M AmeriHealth Caritas User Acess Request Form (PDF)
• 3M Dashboard Step-by-Step User Guide (PDF) 
• ACT outcomes reporting form with instructions (PDF)
• Adverse incident reporting form (PDF)
• Adult and geriatric community-based treatment guidelines (PDF)
• Applied behavioral analysis (ABA) treatment request for a functional assessment form (PDF)
• Applied behavioral analysis (ABA) treatment request form (PDF)
• Authorization fax request form (PDF)
• Behavioral health adult assessment (PDF)
• Behavioral health adult mental health rehabilitation treatment request form (PDF)
• Behavioral health attestation for specialized provider requirement(s) (PDF)
• Behavioral health child and adolescent mental health rehabilitation treatment request form (PDF)
• Behavioral health certificate of need for psychiatric hospitalization or psychiatric residential treatment facility (PRTF) (PDF)
• Behavioral health discharge note (PDF)
• Behavioral health medical screening form (PDF)
• Behavioral health outpatient treatment request (OTR) form (PDF)
• Behavioral health progress note template (PDF)
• Behavioral health provider enrollment form (PDF)
• Behavioral health psychiatric residential treatment facility referral form (PDF)
• Behavioral health psychological/neuropsychological testing request form (PDF)
• Behavioral health treatment plan template (PDF)
• Certification of ambulance transportation form (PDF)
• Community brief crisis support request form (PDF)
• Consent for abortion (PDF)
• Consent for hysterectomy (PDF)
• Consent for sterilization (PDF)
• Consent for sterilization (Spanish) (PDF)
• Contract request form (PDF)
• Crisis intervention follow-up request (PDF)
• Department of Health and Hospitals newborn eligibility system user manual (PDF)
• Electric breast pump request form (PDF)
• EPSDT personal care services (PDF)
• Health and wellness questionnaire (PDF)
• Hospice certificate of terminal illness (PDF)
• Hospice notice of election (PDF)
• Hospice notice of election concurrent care (PDF)
• Hospital notification of emergency/urgent admission (PDF)
• Independent review provider reconsideration form (PDF)
• Infant/child referral for WIC certification and information transfer form (PDF)
• Initial crisis intervention notification request (PDF)
• Let Us Know - Member intervention request form (PDF)
• Let Us Know - Member intervention request form (Spanish) (PDF)
  
• Louisiana Uniform Prescription Drug PA request form (PDF)
  
• Medicaid program acknowledgement of receipt of hysterectomy information (PDF)
• Member's choice in provider (PDF)
• Multiple claims project sheet (PDF)
• National Quality Forum serious reportable events in health care (PDF)
• Non-participating provider emergency services payment guidance (PDF)
• Notification of pregnancy (PDF)
• Optum referral form (PDF)
• Patient consent for provider to file appeal form (PDF)
• Patient health questionnaire (PHQ-9) (PDF)
• Patient health questionnaire for adolescents (PHQ-A) (PDF)
• Patient stress questionnaire (PDF)
• Primary Care Provider (PCP) Selection Form (PDF)
• Provider change form (PDF)
• Provider dispute form (PDF)
• Provider enrollment form (PDF)
• Psychiatric Residential Treatment Facility (PRTF) Authorization Request Form (PDF)
• Substance abuse discharge note (PDF)
• TeleECHO™ Clinic Case Presentation Form (PDF)
• Wait and See Period Attestation Form (PDF)