Page Updated On 03/01/2022
Prior Authorization
Medicare Advantage Prior Authorization
Behavioral Health Prior Authorization
Initial Mental Health 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
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.