Forms

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:


Allegheny/ALDA/ALMH: 888-251-0087 CCBH_ICPAllegheny@ccbh.com
Blair: 855-480-7029 CCBH_ICPBlair@ccbh.com
Bedford/Somerset: 833-622-3982 CCBH_ICPBS@ccbh.com
Delaware: 833-995-2002 CCBH_ICPDelawareCo@ccbh.com
Carbon/Monroe/Pike: 866-562-2405 CCBH_ICPCMP@ccbh.com
Chester: 888-589-6559 CCBH_ICPChester@ccbh.com
Erie: 855-892-8495 CCBH_ICPErie@ccbh.com
Lycoming/Clinton: 855-346-7318 CCBH_ICPLC@ccbh.com
Northeast Moosic:

Lackawanna, Luzerne,
Susquehanna, Wyoming

 866-284-9184 CCBH_ICPNE@ccbh.com
North Central Dubois:

Cameron, Clarion, Clearfield,
Elk, Forest, Jefferson,
McKean, Potter, Warren

 866-294-1142 CCBH_ICPNC@ccbh.com
North Central Moosic:

Bradford, Columbia, Montour,
Northumberland, Schuylkill, Snyder,
Sullivan, Tioga, Union, Wayne

 866-558-2618 CCBH_ICPNC@ccbh.com
North Central Pittsburgh:
Greene		 888-251-0087 CCBH_ICPNC@ccbh.com
North Central State College:

Centre, Huntingdon, Juniata, Mifflin

 866-562-2406 CCBH_ICPNC@ccbh.com
York/Adams/Berks: 866-418-0366 CCBH_ICPYAB@ccbh.com

Please fax the completed form to 1-888-251-0087.

Beginning 11-9-23, Neurological and Psychological Testing Preauthorization Requests can be submitted via ePortal. Please consult our Member Services Guide or contact your Provider Representative if assistance is needed. This form will be discontinued on 2-5-24.

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.

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.

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.

Providers are encouraged to report SMIs to Community Care via the ePortal. For more information, see our guide.