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Behavioral Health Forms
The following behavioral health forms can be used for Hoosier Healthwise and HIP:
Behavioral Health/PMP Communication Form
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MS Word Behavioral Health/PMP Communication Form
Behavioral Health Referral Form
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When to Refer to a Behavioral Health Provider Guide
Neuropsychological Testing Request Form
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MS Word Neuropsychological Testing Request Form
Outpatient Treatment Request Form
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MS Word Outpatient Treatment Request Form
for Hoosier Healthwise and HIP
Psychological Testing Request Form
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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.
Page updated 02/08/2022
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