For best results, please download forms and view with Adobe Reader. For assistance, please view our Technical Assistance tip sheet..
Forms are applicable to All Counties unless otherwise specified.
Typed responses are preferred, or ensure handwriting is legible. If illegible, form may be returned for correction.
Please submit completed forms via fax or secure email to the appropriate county:
|North Central Dubois:
Cameron, Clarion, Clearfield,
|North Central Moosic:
Bradford, Columbia, Montour,
|North Central Pittsburgh:
|North Central State College:
Centre, Huntingdon, Juniata, Mifflin
Coordination of Benefits
Please fax the completed form to 1-888-251-0087.
Evaluation and Testing
Family Based Mental Health Services (FBMHS)
FBMHS are evaluation and treatment services provided to a specific child in a family, but focuses on strengthening the whole family system to increase their ability to successfully manage their child's behavioral and emotional issues. Services are provided by licensed agencies employing a mental health professional and a mental health worker as a team to provide treatment and case management interventions. Services are provided in the home of the family.
Fraud, Waste and Abuse
Intensive Behavioral Health Services (IBHS)
Intensive Behavioral Health Services (IBHS) is an array of therapeutic interventions and supports provided to a child, youth, or young adult in the home, school, or other community setting. Under IBHS, qualified and licensed providers can offer individual, group, ABA, and evidence-based treatments for children and youth. OMHSAS has created an IBHS website and training link where you can find recordings of OMHSAS trainings, links to forms, and important information about becoming a licensed IBHS provider, as well as frequently asked questions. Providers are encouraged to check this IBHS website for up-to-date information.
Please reference the IBHS Packet Checklist below for timeframes and packet requirements.
Mental Health Partial
Release of Information Forms
Residential Treatment Facility (RTF) and CRR Host Home
RTF services are comprehensive mental health treatment services for children with severe disturbances or mental illness. These services are provided in Residential Treatment Facilities (RTFs) which must be licensed by OCY&F under Chapter 3800. The facility must have a service description approved by OMHSAS, be certified by OMHSAS through annual on-site review, have a utilization review plan in effect and be enrolled in the MA program.
Significant Member Incidents
Providers are encouraged to report SMIs to Community Care via the ePortal. For more information, see our guide.