Forms

California Grievance and IMR Forms

Clinician Application and Update Forms

• Apply to the Optum Clinician Network
• Clinician Tax ID - Add / Update Online Form / Paper Form (for contracted Optum clinicians only - to add, update or inactivate a Tax ID)
• Clinician Tax ID - Add / Update Form (TennCare Medicaid Network only)

Confidential Exchange of Information Form

Member Informed Consent Form (sample)

OHBS-CA Release of Information Form

• English
• Chinese
• Spanish

Optum Release of Information Form

Patient Financial Responsibility Forms

• Optum
• OHBS-CA
  • Chinese
  • Spanish

Psychological Testing Request Forms

• Optum Psych Testing Request Form - electronic submission
  • Includes Optum Behavioral Health
  • GHLP Michigan
  • Oxford
• KanCare Psych Testing Request Form
• Medica Psych Testing Request Form

Site Audit Tools

• ABA Agency Audit Tool
• ABA Record Audit Tool
• Case Management Record Audit Tool
• Case Management Site Audit Tool
  
• Clinician Site Audit Tool
• Clubhouse Site Audit Tool
• CMHC/Agency Site Audit Tool
  
• Facility Site Audit Tool
• Home Office Audit Tool
• Peer Support Audit Record Tool
• Peer Support Site Audit Tool
• Psychosocial Rehab Record Audit Tool
• Sitter Service Agency Audit Tool
• Sitter Service HR File Audit Tool
  
• Supervisory Protocol
• Supervisory Protocol (MN only)
• Treatment Record Audit Tool

Uniform Treatment Plans (UTP)
Fax completed UTP forms to 1-877-235-9905, unless requesting TX SB 58 Services. If requesting TX SB 58 Services, fax completed TX UTP to 1-877-450-6011

• Indiana UTP
• Maryland UTP
• Texas UTP

Wellness Assessment Forms * does not apply to Unison membership

Wellness Assessments are available here, on the Forms page, at the secured user section, or by mail.

The Wellness Assessments here can be printed blank or, with the editable form, you can type in the information for the top section before printing the form.

Adult Wellness Assessment (English): blank or editable

Youth Wellness Assessment (English): blank or editable

Adult Wellness Assessment (Spanish): blank or editable

Youth Wellness Assessment (Spanish): blank or editable

WA Instruction Page:  English or Spanish

Sample completed WA: English or Spanish

WA Client Education Sheet

Wellness Assessments are also available at the secure transaction section of Provider Express for registered users!

Log in and click on the ALERT tab. Here you can print out Wellness Assessments that can be pre-populated with the name of the clinician* and member name.
*Note: A clinician number will be pre-populated on the form. For the confidentiality of those clinicians whose Tax ID is their social security number, all clinician numbers presented on these WA forms are Optum-assigned numbers.

Notes about the Wellness Assessment forms:

• It is advised to download each Wellness Assessment rather than copy because photocopying will deteriorate the face quality of the form which could lead to technical difficulties in the ability of Optum to read the forms when you fax them to us.
• There is only one Wellness Assessment form; it is the same one that is offered to members at the first and second time.

All outpatient and EAP claims should be submitted electronically via Provider Express or EDI. For faster claims reminbursement with less hassle, it is strongly encouraged that you sign up for electronic funds transfer (EFT) via Optum Pay.

Inpatient claims may be submitted through Electronic Data Interchange (EDI) through the clearinghouse of your choice.  For paper claim submission, facilities should use the industry standard UB-04 claim form using contracted revenue codes.  

Claims that need to be filed on paper should be done on the red 02/12 1500 Claim Form. Click to see a sample 1500 form, a listing of all Optum required fields, as well as the reverse side of the 1500 Claim Form.

Click here to learn where to submit Optum Claim forms

To receive copies of the 02/12 1500 Claim Form, contact:

• Your current forms supplier;
• TFP Data Systems: 1500form@tfpdata.com or 800-482-9367 ext. 58029; or
• The Government Printing Office: http://bookstore.gpo.gov/catalog/government-forms-phone-directories or 866-512-1800
   

NJ Out-of-Network Inadvertent/Involuntary Claims Negotiation Request Form

NY State Out-of-Network Surprise Medical Bill Assignment of Benefits Form

ASAM Levels of Care

California Grievance and IMR Forms

Confidential Exchange of Information Form

Coordination of Care Checklist

Disability Solutions Program Forms

• CAGE-AID
• Client Information & History Form
• Clinician Expertise/Specialty Attestation
• Disability Solutions Manual
• Disability Solutions Program Overview
• Disability Solutions Checklists
• Memorandum of Understanding
• Psychiatric & Functional Assessment Form
   

Idaho Targeted Care Coordination

• Optum Idaho Optum Supports & Services Manager (OSSM)
• Blank Person-Centered Service Plan Form in English
  
• Blank Person-Centered Service Plan Form in Spanish
   

Long-Acting Injectable (LAI) Medication

Nebraska Medicaid - Audit Tools

• Case Management Record Tool
• Clinician Site Tool
• Organizational Provider Site Audit Tool
• Psychosocial Rehab Record Tool
• Supervisory Protocol Tool
• Treatment Record Tool
   

OHBS-CA Release of Information Forms

• English
• Chinese
• Spanish
   

Screening Tools - the tools below are provided as a resource to aid in the screening of alcohol and drug use.

• APA DSM5 Level 2 Substance Use Adult: DSM5 adult substance use questionnaire
• APA DSM5 Level 2 Substance Use Parent of Child Age 6 to 17: DSM5 child and adolescent substance use questionnaire
  
• AUDIT-C: Adult alcohol use questionnaire
• CAGE: Adult alcohol use questionnaire
• CAGE-AID: Adult alcohol and drug use questionnaire
• CRAFFT (Self-Administered): Adolescent alcohol and drug use questionnaire
• CRAFFT (Practitioner-Administered): Adolescent alcohol and drug use questionnaire
• SBIRT: Screening, Brief Intervention, and Referral to Treatment
   

Transcranial Magnetic Stimulation (TMS) & Electroconvulsive Therapy (ECT) Forms

• TMS & ECT Authorization Request Form (NEW) - electronic submission

Uniform Treatment Plans (UTP)
Fax completed UTP forms to 1-877-235-9905, unless requesting TX SB 58 Services. If requesting TX SB 58 Services, fax completed TX UTP to 1-877-450-6011

• Indiana UTP
• Maryland UTP
• Texas UTP
   

Washington (state) IMC Critical Incident Report Form

Wellness Assessment Forms * does not apply to Unison membership

• English version: Adult or Child-Adolescent
• Spanish version: Adult or Child-Adolescent

Disclosure Provider Form – Individual

Disclosure Provider Form - Entity

Disclosure Provider Form – Roster Template (Excel file)

Disclosure Provider Form – Roster Addendum

Optum Disclosure of Ownership Form FAQ

MN Care Advocate’s Fax # is 1/855-454-8155

MN Autism and EIDBI Forms and Information

Mental Health Intensive Outpatient Program Forms

• Initial IOP (non-contracted providers only)
• Continued IOP (non-contracted providers only)
   

MH TCM

• TCM Powerpoint Presentation
• TCM Authorization Form
• MBH TCM Need for DTR Notification
• MBH TCM DTR Letter
• Medica Member Appeal Rights
• MBH TCM Discharge Criteria
• Telephonic Support Services - Provider Handout
• MBH Telephonic Support Services - Referral Information for Providers
• Telephonic Support Services - What Members Can Expect
  
  

Substance Abuse Forms

• Medication Assisted Treatment (non-methadone) Request Cover Sheet
  
• Methadone Maintenance Assessment Cover Sheet
• Substance Abuse Retrospective Request Form
• Substance Abuse Service Request Cover Sheet
   

Appointment of Representative Form

Assertive Community Treatment (ACT) Form (for non-contracted providers only)

DBT Request Form (for non-contracted providers only)

Intensive Community Based Services (ICBS) Form

Intensive Community Based Services (ICBS) Monthly Update Form

Mental Health Retrospective Request Form - Medica Behavioral Health - MN CAC

Psychological Testing Form