Forms

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Forms for Behavioral Health Providers


Behavioral Health Urgent Care Provider Template

This template should be used by Behavioral Health Urgent Care providers when submitting quarterly reports.

download iconBHUC Measures Reporting Template (Excel)

Community Support Program (CSP) Authorization Form

Please go to the Service Authorizations page for the CSP Authorization Form.

MBHP Organizational Providers Subcontracting Application 

In the event that a provider wishes to engage any subcontractors to assist with its obligations to provide Covered Services, the provider must:
•Complete the MBHP Organizational Providers Subcontracting Application and provide a written description of any subcontracted relationships to the MBHP Network Operations Department no later than 60 days prior to the agreement;
 •  Maintain all subcontracts or agreements in writing;
•Monitor the quality of care provided to Members under the MBHP agreement and any subcontract;
•Remain fully responsible for meeting all of the terms and requirements of the provider agreement. No provider agreement or subcontract agreement will relieve the provider of its legal responsibilities under the provider agreement; and
•Submit claims for the delivery of all services in accordance with MBHP’s claims policies and procedures. Claims must contain the name and tax ID number of the provider who has the contract with MBHP.  MBHP reserves the right to determine approval or denial of all subcontractor agreements.
Information can be submitted in writing by emailing to MBHP_PR@carelon.com.

ProviderConnect Inpatient Discharge Review Instruction Guide

This instruction guide is used when completing a discharge review in ProviderConnect.

download iconProviderConnect Inpatient Discharge Review Instruction Guide

Repetitive Transcranial Magnetic Stimulation (rTMS) Request form

Providers should fill out this form when seeking rTMS services.  This must be completed and faxed back to us for consideration of services.

download icon rTMS Request form


Integrated Care Management Program (ICMP) Referral Form

The ICMP accepts direct referrals from providers and Members.  To make a referral, you can access the online ICMP Referral form, download a PDF, or call 1-800-495-0086, Ext. 706870.

Provider Adverse Incident Report Form

Facilities use this form to notify MBHP of an incident.

download iconProvider Adverse Incident Report form (PDF)

Claim Review Form

The claim review form should be used for claims appeals when a claim is paid or denied incorrectly according to payment policies, authorizations, or required attachments such as EOBs and letters for TPL. We have updated the form for the purpose of administrative simplification, combining three previously used forms into one.

Please use this form for the following situations:
download iconClaim Review form

Claim Review - Additional Members Form

If multiple Members are impacted by the same scenario, please use the Additional Members form to notify us of the other Members. Please attach this form to the Claim Review form when sending. This is intended to reduce the number of individual claim reviews.

download iconClaim Review - Additional Members form

Children's Behavioral Health Initiative (CBHI) Service Authorization Information Form

Additional Units Request Form
This template should be used by Therapeutic Mentoring (TM) providers, In-Home Behavioral Services (IHBS) providers, In-Home Therapy (IHT) providers, and Family Support and Training (FS&T) providers to submit requests to MBHP for additional units within an existing authorization period.

For this form, visit the Service Authorizations page >

Extended Outpatient Treatment Request (EOTR) Forms


Adult Extended Outpatient Treatment Screen >

Child/Adolescent Outpatient Treatment Screen >

Extended Outpatient Day Treatment Screen >

Track my EOTR submissions >

Substance Use Disorder Treatment Request Forms

Please go to the Service Authorizations page for the SOAP Extension Form and Tracking Form for Substance Use Disorder Treatment Request Submissions.

Psychological Evaluation Request (PER) Form

This form must be filled out and submitted, and authorization must occur, prior to any psychological/neuropsychological testing.  Please go to the Service Authorizations page for the Psychological Evaluation Request (PER) Form.


Integrated Forms for Behavioral Health Providers and Primary Care Clinicians


Behavioral Health Providers and Primary Care Clinicians "Two Way" Communication Form

This single form  can be used by all MassHealth providers to facilitate communication. Behavioral health providers and PCCs can use the form when communicating with one another about a MassHealth Member.  The primary purpose of this quality improvement initiative is to increase the frequency and the quality of the content of communication between behavioral health providers and primary care clinicians.

download iconTwo-Way Communication Form

Forms for Members


Health Needs Assessment

This survey is for Members of the Primary Care Clinician (PCC) Plan. It asks questions about you and some factors that may affect your health.This information will help MBHP better understand your needs. We can use it to identify resources that may be helpful to you. Your responses are confidential and will only be used to find ways MBHP can help you. If you need help completing the survey, please call the MBHP Member Engagement Center at 800-495-0086.

Take the Health Needs Assessment >

Authorization for MBHP/Carelon Behavioral Health to Release Confidential Information 

You or your authorized representative can fill this form out to give your providers or other organizations permission to view your personal health information (PHI).

download iconAuthorization to Release Confidential Information
download iconAutorizacion Para Revelar Divulguen Informacion Confidencial

Request for Accounting of Disclosures of Protected Health Information (PHI) 

You or your authorized representative can request an accounting of disclosures by completing and submitting this form.

download iconRequest for Accounting of Disclosures of PHI
download iconSolicitud del Informe de la Informacion Personal Divulgada de la Salud (PHI)

Request for Amendment to a Member Record

You or your authorized representative can request that an amendment (change) to be made to the personal health information (PHI) in your MBHP care management record or designated record set (DRS).

download iconRequest for Amendment to a Member Record
download iconSolicitud de Enmienda del Registro de un Miembro

Request for Designated Record Set

You can ask MBHP for your health care records, also known as your Designated Record Set.  Just fill out this form and return it to MBHP.  You may also have someone you trust, called an authorized representative, to help you fill out this form.

download iconRequest for Designated Record Set
download iconSolicitud del Conjunto de Expedientes Designados

Request for Restriction of Use and Disclosure

MBHP must disclose health information in order to conduct its business operations.  Information about these disclosures is available at www.masspartnership.com.  You or your authorized representative can ask MBHP to limit the disclosure of your protected health information (PHI).  MBHP will consider your request, but it is not required by law to honor your request.

download iconRequest for Restriction of Use and Disclosure
download iconSolicitud de Restriccion de Uso y Divulgacion