Prior Authorization

Initial Mental Health Request Form

AODA Initial Request Form

Do not use these forms to request prior authorization (PA) for TMS. 

A PA is only required for outpatients if the request is for services with an out-of-network provider.

Mental Health Treatment Extension Request

AODA Extension Request Form

Use these forms to request an extension of a previously approved request.

Transcranial Magnetic Stimulation Request Form

This form is used without the Initial Mental Health Treatment Request. 

Eating Disorder Supplemental Request Form

This form is used in addition to the Initial Mental Health Treatment Request or the Mental Health Treatment Extension Request forms.