Alternative Therapies for Chronic Pain Management

Alternative Therapies for Chronic Pain Management

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Inpatient Authorization Request

In order to ensure our members receive quality care, appropriate claims payment, and notification of servicing providers, please complete this form in its entirety. Please type or print in black ink and submit this request to the fax number below.

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Electroconvulsive Therapy Services as Covered Form

Behavioral Health Service Request Form

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PHP and IOP Services as Covered Form

Behavioral Health Service Request Form

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Residential Treatment Request Form

Behavioral Health Service Request Form

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Curves Baseline/Outline Form

Please complete the OUTCOME* and DATE* columns of the form with the member’s current outcome data.

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Weight Watchers Baseline Form

In order to begin the program, members will need to have you complete the attached baseline form.

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Alternative Therapies for Chronic Pain Management Referral Form

Alternative Therapies for Chronic Pain Management Referral Form

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