Provider Forms

Clinical

• Spravato Provider Authorization Form
• Spravato Pharmacy Prior Authorization Form
• ICC Referral Form
• Higher Level of Care Frequently Asked Questions
• Inpatient Registration Quick Reference Document
• PRTF Referral Form
• Solnit Hospital Referral Form
• Appointment of Authorized Representative
• Release of Information (English)
• Release of Information (Spanish)
  • ROI Template Example
• Authorization for Carelon Behavioral Health to Release Designated Record Set Information

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Provider Relations

• Behavioral Health Dual Coverage Frequently Asked Questions
• Facility Provider Data Verification (PDV) Form
• Individual Practitioner Data Verification (PDV) Form
• Group Practice Data Verification (PDV) Form