UBH Forms

Clinician Application Forms

• Apply to the UBH Clinician Network
  
• Clinician Add/Change Forms

Wellness Assessment Forms

• English version: Adult or Child-Adolescent
• Spanish version: Adult or Child-Adolescent

Prior Authorization Exception Form

• Exception to Prior Authorization Requirement Request

Benefit Transition Notification Form

• Benefit Transition Notification

Claim Forms

• All outpatient claims should be submitted on a red CMS-1500 claim form. More information is available about submitting claims on this form at the CMS site. Click to see a listing of all CMS-1500 UBH required fields.

• UB92 (CMS-1450) claim form – Inpatient claims are typically submitted on a UB92 claim form. You can check the Standard Register Company Web site for information on ordering UB92 (CMS-1450) Claim Forms.

• Claim Inquiry/Adjustment Request Form

Psychological Testing Request Form

• UBH/PBH Psych Testing Request Form
• UBH/PBH Psych Testing Request Printable On-Line Form

Disability Solutions Program Forms

• Memorandum of Understanding
  
• Specialty Attestation
  
• Client Information & History Form
  
• Psychiatric & Functional Assessment Form
  

EAP Forms

• UBH EAP Claim form
  
• EAP Member Statement of Understanding

Sample Forms and Letters

• EAP Authorization Letter Sample


• EAP Claim Form Sample


• Sample Patient Financial Responsibility Form


• Exchange of Information Form
(also for use with HPHC members)

• Client Information and Office Policies Statement - Informed Consent Sample
• Clinical Assessment
• Child Adolescent Assessment Addendum
• General Disclosures
• Employee Confidentiality Statement
• New Patient Intake
• Mental Health Treatment Plan
• Progress Note - MD Update
• Progress Note - Page 2
• Chart Prescription Log
• No-Show Discharge Letter
• No-Show Form
• Prescription Expiration Log
• Discharge Tracking

Site Audit Tools

• Clinician Site Audit Tool


• Facility Audit Tool


• Home Office Audit Tool


• Supervisory Protocol Tool


• Treatment Record Review Tool

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