This page contains Behavioral Health forms for providers to use when communicating with Highmark.
- Authorization for Behavioral Health Providers to Release Medical Information
- Behavioral Health Authorization Request Form
- Communication Document for Behavioral Health Specialist To Primary Care Physician
- Discharge Summary Fax Template
- Outpatient Behavioral Health (BH) - ABA Requests: Service Authorization Request - applies to members of FEP and employees of PNC, Albertsons, and Centene
- Consent for Care Management Services for Inpatient Residential Treatment Care - applies to members of FEP
Fax consent form and treatment plan to 1-888-663-0261.
Residential Treatment Center (RTC) must be accredited by a nationally recognized organization and licensed by the state, district, or territory to provide residential treatment for medical conditions, mental health conditions, and/or substance abuse.
- Precertification prior to admission
- A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC), and case manager in the Local Plan where the RTC is located prior to admission.
- Member must be enrolled and participating in case management through the Local Plan when the care is medically necessary for treatment of a medical, mental health, and/or substance abuse condition.
- FEP Nondiscrimination Notice
Last updated on 1/13/2022