Forms & publications

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Acute inpatient rehabilitation authorization update

13-839

Acute physical medicine and rehabilitation (PM&R) update form.

Form

Acute physical medicine and rehab admit/extension prior authorization request

13-838

Use this form to request admission or extension for acute physical medicine and rehab services.

Form

Appendix F - Instructions to fill out the General Information for Authorization Request form

Instructions on how to complete the General Information for Authorization Request form.

Provider guide

Appendix G - How to check status of an authorization

Directions on how to check status of authorization requests through ProviderOne and the interactive voice response system.

Provider guide

Applied Behavior Analysis (ABA) level of support requirement

12-411

Use this form to request authorization. A copy of the COE evaluation, the prescription for ABA services, the Board Certified Applied Behavior Analyst’s (BCABA) assessment with the functional analysis, and the BCBA’s treatment plan must be attached to this request.

Form

Authorization for ambulance/secure transportation under the Involuntary Treatment Act (ITA)

42-0003

Use this form for mental health transports and for substance use disorder transports.

Form

Authorization for Transportation to an Evaluation and Treatment Facility

13-680

Use this form when transporting a mental health or chemical dependency client from the field directly to an evaluation and treatment facility.

Form

Bathroom equipment authorization form (13-872)

13-872

Use this form to request and provide medical justification for bathroom equipment.

Form

Billing with two authorization numbers

A guide to assist with billing two authorization numbers on a claim.

Fact sheet

Compression garments authorization form (13-871)

13-871

Use this form to request and provide medical justification for compression garments.

Form

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