For best results, please download forms and view with Adobe Reader.

Please submit completed forms via fax or secure email to the appropriate county:

Allegheny:                               888-251-0087 |
Blair:                                          855-480-7029 |
Bedford/Somerset:                 833-622-3982 |
Carbon/Monroe/Pike:            866-562-2405 |
Chester:                                    888-589-6559 |
Erie:                                           855-892-8495 |
Lycoming/Clinton:                  855-346-7318 |
Northeast Moosic:                  866-284-9184 |
North Central Dubois:            866-294-1142 |
North Central Moosic:            866-558-2618 |
North Central Pittsburgh:       888-251-0087 |
North Central State College:  866-562-2406 |
York/Adams/Berks:                   866-418-0366 |

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.

Intensive Behavioral Health Services

SUD Case Management Referral

SUD Precertification Template

SUD Continued Stay Review Template

Community-Based Adolescent SUD Treatment Service Referral Form

SUD Case Notification Form

2.5 PHP Services (Substance Use Partial)

Mental Health Partial Program Notification: Adult

Non-Acute Child/Adolescent Partial ISPT Meeting Attendance Request

Mental Health Partial Program Notification: Child/Adolescent

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.


Prescription Letter

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.

Life Domain BP Format for Evaluations

Guidelines for Addendums to Evaluations

Plan of Care Form and Directions

ISPT Invitation Form

ISPT Sign In Sheet

ISPT Summary

Family Choice Notification

Attachment 8

RTF Family Roles & Responsibilities

CRR Host Home Family Roles & Responsibilities

Allegheny County Drug & Alcohol forms

2.5 PHP Services (Substance Use Partial)

Family Focused Services

Joint Planning Team Referral Form

Mobile Transition Age Youth Program

ECSC & IDDT Referral Form

Dual Diagnosis Treatment Team (DDTT) Referral Form

Neuro/Psychological Testing Preauthorization Request

Mental Health Precertification Template - Adult

Mental Health Precertification Template - Child

Mental Health Continued Stay Review Template

Prescribing Practitioner Reporting

Specialized Services Continued Stay Review

Extended Evaluation Service

Child/Adolescent Music Therapy

Specialized Evaluation

Project Transition Referral

CASSP Coordinator Notification Form

Mobile Medication

New Connections (BHNHTD) Referral Form

All Counties Discharge

All County ROIs

Coordination of Benefits Discharge Review

Beginning 12-1-20, providers are encouraged to report SMIs to Community Care using our convenient new process in ePortal. For more information, see our guide.

Significant Member Incident Report Form

All Counties Fraud, Waste and Abuse Forms

All Counties Network Management Forms