USBHPC Forms

Clinician Application Forms

• Apply to the UBH/USBHPC 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.

Psychological Testing Request Form

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

EAP Forms

• USBHPC 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


• Consent for Release of Confidential Information Form Sample


• Confidential Exchange of Information Form


• Client Information and Office Policies Statement - Informed Consent Sample

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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