MDwise

The following behavioral health forms can be used for Hoosier Healthwise and HIP:

• Behavioral Health/PMP Communication Form | MS Word Behavioral Health/PMP Communication Form
• Behavioral Health Referral Form | When to Refer to a Behavioral Health Provider Guide
• Neuropsychological Testing Request Form | MS Word Neuropsychological Testing Request Form
• Outpatient Treatment Request Form | MS Word Outpatient Treatment Request Form for Hoosier Healthwise and HIP 
• Psychological Testing Request Form | MS Word Psychological Testing Request Form
• Medically Frail Referral Form

Substance Use Disorder Forms:

• Residential/Inpatient Substance Use Disorder Treatment Prior Authorization Request Form - This form must be used to request PA for inpatient and residential SUD treatment services, rather than using the standard universal PA request form.
• Initial Assessment Form for Substance Use Disorder Treatment Admission - This assessment form must be completed and submitted as an attachment to the SUD residential and inpatient treatment PA request form for initial admissions.
• Reassessment Form for Continued Substance Use Disorder Treatment - This assessment form must be completed and submitted for requests to extend authorization for residential and inpatient SUD treatment.