Forms

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

Behavioral Health Rehabilitation Services / Intensive Behavioral Health Services

OMHSAS is in the process of rolling out new licensing regulations for what we currently refer to as Behavioral Health Rehabilitation Services (BHRS) for children and youth. The new term for mobile mental health treatment services will be Intensive Behavioral Health Services (IBHS). 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 new IBHS website for up-to-date information. Community Care and county partners will be working closely with current BHRS providers to prepare for the transition to IBHS. Please contact your Provider Representative when you are ready to bill for IBHS.

BHRS are treatment and therapeutic interventions prescribed by a psychologist or psychiatrist provided on an individual basis in the person's own environment such as the home, school and community. These services include Therapeutic Support Staff (TSS), Behavioral Specialist Consultants (BSC), Mobile Therapy (MT) and specialized services, as approved.

When submitting a packet, 6 items are required: the Best Practices Evaluation, the Individual Treatment Plan, and the 4 forms that are labeled *required for packet submission below.

Substance Use Disorder (SUD) Services

SUD Case Management Referral

@{ file.title }

SUD Precertification Template

@{ file.title }

SUD Continued Stay Review Template

@{ file.title }

SUD Discharge Template

@{ file.title }

Community-Based Adolescent SUD Treatment Service Referral Form

@{ file.title }

SUD Case Notification Form

@{ file.title }

Mental Health Partial and 2.5 PHP (Substance Use Partial) Services

2.5 PHP Services (Substance Use Partial)

@{ file.title }

Mental Health Partial Program Notification: Adult

@{ file.title }

Non-Acute Child/Adolescent Partial ISPT Meeting Attendance Request

@{ file.title }

Mental Health Partial Program Notification: Child/Adolescent

@{ file.title }

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.

Precertification

@{ file.title }

Best Practice Prescription Letter

@{ file.title }

Residential Treatment Facility (RTF)

RTF services are comprehensive mental health treatment services for children with severe disturbances or mental illness. These services are provided in Residential Treatment Facilities (RTF's) 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

@{ file.title }

Guidelines for Addendums to Evaluations

@{ file.title }

Plan of Care Form and Directions

@{ file.title }

ISPT Invitation Form

@{ file.title }

ISPT Sign In Sheet

@{ file.title }

ISPT Summary

@{ file.title }

Family Choice Notification

@{ file.title }

Attachment 8

@{ file.title }

Discharge Summary

@{ file.title }

RTF Family Roles & Responsibilities

@{ file.title }

CRR Host Home Family Roles and Responsibilities

@{ file.title }

ALDA

Allegheny County Drug & Alcohol forms

2.5 PHP Services (Substance Use Partial) and 2.1 IOP Services (Intensive Outpatient)

@{ file.title }

Other Services

Family Focused Services

@{ file.title }

Joint Planning Team Referral Form

@{ file.title }

Joint Planning Team Authorization Form

@{ file.title }

Mobile Transition Age Youth Program

@{ file.title }

ACT/CTT

@{ file.title }

ECSC & IDDT Referral Form

@{ file.title }

Dual Diagnosis Treatment Team (DDTT) Referral Form

@{ file.title }

Neuro/Psychological Testing Preauthorization Request

@{ file.title }

Mental Health Precertification Template - Adult

@{ file.title }

Mental Health Precertification Template - Child

@{ file.title }

Mental Health Continued Stay Review Template

@{ file.title }

Mental Health Discharge Template

@{ file.title }

Prescribing Practitioner Reporting

@{ file.title }

Specialized Services Continued Stay Review

@{ file.title }

Extended Evaluation Service

@{ file.title }

Child/Adolescent Music Therapy

@{ file.title }

Specialized Evaluation

@{ file.title }

Project Transition Referral

@{ file.title }

CASSP Coordinator Notification Form

@{ file.title }

Mobile Medication

@{ file.title }

Release of Information Forms

All County ROIs

@{ file.title }

Coordination of Benefits

Coordination of Benefits Discharge Review

@{ file.title }

Significant Member Incidents

Significant Member Incident Report Form

@{ file.title }

Fraud, Waste and Abuse

All Counties Fraud, Waste and Abuse Forms

@{ file.title }

Forms

Behavioral Health Rehabilitation Services / Intensive Behavioral Health Services

Intensive Behavioral Health Services

TSS Schedule Forms (*required for packet submission)

Life Domain BP Format for Evaluations

Guidelines for Addendums to Evaluations

ISPT Meeting Invitation

Prescriber Responsibilities at ISPT

BHRS Plan of Care Form and Directions

MST and FFT Plan of Care Form and Directions

ISPT Sign In, Confidentiality Statement, Summary and Prescriber Collaboration

Family Choice Notification

Discharge Checklist and Summary

FBA Certification Update

Enhanced School Based Partial Plan of Care Form and Directions

Substance Use Disorder (SUD) Services

SUD Case Management Referral

SUD Precertification Template

SUD Continued Stay Review Template

SUD Discharge Template

Community-Based Adolescent SUD Treatment Service Referral Form

SUD Case Notification Form

Mental Health Partial and 2.5 PHP (Substance Use Partial) Services

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

Family Based Mental Health Services (FBMHS)

Precertification

Best Practice Prescription Letter

Residential Treatment Facility (RTF)

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

Discharge Summary

RTF Family Roles & Responsibilities

CRR Host Home Family Roles and Responsibilities

ALDA

2.5 PHP Services (Substance Use Partial) and 2.1 IOP Services (Intensive Outpatient)

Other Services

Family Focused Services

Joint Planning Team Referral Form

Joint Planning Team Authorization Form

Mobile Transition Age Youth Program

ACT/CTT

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

Mental Health Discharge 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

Release of Information Forms

All County ROIs

Coordination of Benefits

Coordination of Benefits Discharge Review

Significant Member Incidents

Significant Member Incident Report Form

Fraud, Waste and Abuse

All Counties Fraud, Waste and Abuse Forms

TSS Schedule Forms (required for packet submission)*