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Carelon Behavioral Health of Connecticut Carelon Behavioral Health of Connecticut
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Home / Providers / Provider Forms

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)
  • Authorization for Carelon Behavioral Health to Release Designated Record Set Information

Provider Relations

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

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