Provider Forms & Tools

• Appeal Request Form
• Consent for Appeal Form (English)
• Consent for Appeal Form (Spanish)

• ABA Therapy Initial Request Form

• Behavioral Health and Substance Use Disorder
• Mental Health Technology Transfer Center Network (MHTTC) – Training and technical assistance (TA) in evidence-based practices (EBP)
• Evidence-Based and Research-Based Best Practices  – Reporting Guidelines (HCA)
• IMC Evidence-Based Practices Reporting Guidelines
• Clinical Practice Trainings and Resources for Integrated Managed Care
• Depression Screening for Caregivers (Children & Youth)
• Seattle Children’s Partnership Access Line (PAL)
• Partnership Access Line (PAL) for Moms
• Patient Health Questionnaire (PHQ) Screeners
• CALOCUS
• CALOCUS Score Sheet
• LOCUS
• LOCUS Score Sheet

• Dialysis Notification Form
• Care Management Referral Form
• Care Management Referral Programs
• Chemical Dependency OTR Form
• Critical Incident Form
• Mental Health OTR Form
• My Life Plan – A Person-Centered Planning Guide is funded by the Washington State Developmental Disabilities Council.
• Patient Complaint Form
• Pregnancy Notification Form
• Psych/Neuropsych Testing Request Form
• Quality Improvement Program

• Child Development Supports
• Parents Helping Parents
• Depression Screening for Caregivers (Children & Youth)

• ChildrenFirst™ Prenatal Form (online)
• More Information: Prenatal Program
• ChildrenFirst™ Well Child Program Form (online)
• More Information: Well Child Program

• Claims Supporting Documentation Cover Sheet
• Corrected Claim – Standard Cover Sheet
• Hysterectomy Consent Form: Prior authorization and a consent form are required for hysterectomy. See our Provider Manual for more information.
• Sterilization Consent Form: A consent form is required for sterilization. See our Provider Manual for more information.
• Sterilization Consent Form – Spanish: A consent form is required for sterilization. See our Provider Manual for more information.
• 1500 Claim Form and Instructions
• UB04 Claim Form and Instructions

• Authorization to Disclose Protected Health Information
• Authorization to Release Confidential Substance Use Disorder Treatment Information
• Fraud, Waste, and Abuse Training Attestation Form (online)
• Ownership and Control Interest Disclosure Form (online)
• Ownership and Control FAQ
• Report Potential Fraud Form
• Report Potential Privacy/Security Incident Form

See our Provider Manual for more information about electronic transactions.

• 835/ERA Enrollment Form

• Clinic/PCP Selection Form (online)
• Clinic/PCP Selection Form (PDF)
• Member Roster Correction template

• Prescription Order Form for Costco Home Delivery
• Express Scripts Physician Forms

Medication Assisted Treatment (MAT) Program

• Buprenorphine Monotherapy Prior Authorization Form
• Guidelines for Buprenorphine Containing Products
• Guidelines for Naltrexone Containing Products

Opioid Prescription

• Information on the HCA Opioid Policy
• Opioid Attestation Form: Fax the completed attestation form to Express Scripts at 1-877-251-5896
• Opioid Agonists Medical Policy
• Pharmacy Expedited Authorization Codes

• Clinic and Group Add Change Term Form (Please open in Chrome browser)
• Clinic and Group Add Change Term Form (online)
• Clinic and Group Add Change Term Form (PDF)
• Core Provider Agreement for Medicaid Services FAQ
• Provider Add Change Term Form (Please open in Chrome browser)
• Provider Add Change Term Form (online)
• Provider Add Change Term Form (PDF)
• Provider Directory Intake Form
• Behavioral Health Provider Roster

• Pain Management Resources
• Policies and Procedures
• Pricing Methodologies
• Language Assistance Cards

• Exception to Rule Request Form (Apple Health Only)
• Hearing Aid Prior Authorization Request Form
• Limitation Extension Form
• Inpatient Admission Form
• Prior Authorization
• Stage 2 Bariatric Surgery Request
• Standard Referral Form
• SYNAGIS – Statement of Medical Necessity
• Skilled Nursing Facility (SNF) Request Process