Forms and 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
• CBT+ Training
• 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
• Sterilization Consent Form
• Sterilization Consent Form – Spanish
• 1500 Claim Form and Instructions
• UB04 Claim Form and Instructions

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

Please note, 835 Claim Payment Advice and ACH/EFT Electronic Payments are separate transactions and each requires separate enrollment.

See our Provider Manual for more information about electronic transactions.

• 835/ERA Enrollment Form
• ACH/EFT (Electronic Funds Transfer) Form (PDF)
• ACH/EFT (Electronic Funds Transfer) Online Tool
• Vendor ACH Payments Form

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

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

*Beginning June 1, 2021, Walmart pharmacy will no longer be our preferred mail order pharmacy and Costco Pharmacy will be the mail order service for prescriptions.

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