Provider Behavioral Health Unit Documents & Forms
You can reach the Behavioral Health Unit at 1.877.221.9295 (24 hours a day) with any questions. Fax requests for treatment and reporting of crisis encounters to 740.699.6255 or 1.866.616.6255. This is a dedicated fax line that is available to the BHU staff only.
Documents can be ordered by Name (Alpha Ascending or Descending), Date Added or Number of Hits that the document has received to make it easier to find the document you want to download. Simply click on "Order By" Name, Date or Hits and "Ascendant" or "Descendent" and they will automatically repopulate accordingly.
Treatment Continuation Request
| Date added: | 09/27/2011 |
| Filesize: | 1 MB |
| Downloads: | 2057 |
This form is to be used for the Behavioral Health Unit.
Psychological Testing Pre-Authorization Request
| Date added: | 02/01/2011 |
| Filesize: | 591.36 kB |
| Downloads: | 1363 |
This form is to be used for the Behavioral Health Unit.
PreAuthorization Form
| Date added: | 10/05/2010 |
| Filesize: | 1.11 MB |
| Downloads: | 852 |
Initial Authorization for ABA
| Date added: | 04/13/2012 |
| Filesize: | 122.44 kB |
| Downloads: | 309 |
Crisis Encounter Report
| Date added: | 12/12/2007 |
| Filesize: | 428.42 kB |
| Downloads: | 1300 |
This form will aid the transportation of vital behavioral health information from your facility to our Behavioral Health Unit. No pre authorization is needed by the patient. Complete all appropriate information on the form and fax completed form to The Health Plan Behavioral Health Unit at our local fax: 740.699.6255 or toll free fax: 1.866.616.6255.
Continuity of Care Consultation
| Date added: | 05/03/2012 |
| Filesize: | 645.98 kB |
| Downloads: | 503 |
Concurrent/Discharge Form
| Date added: | 10/05/2010 |
| Filesize: | 449.34 kB |
| Downloads: | 746 |
Concurrent Authorization for ABA
| Date added: | 04/13/2012 |
| Filesize: | 122.66 kB |
| Downloads: | 311 |
Authorization to Disclose Health Information to PCP
| Date added: | 05/10/2012 |
| Filesize: | 31.22 kB |
| Downloads: | 15 |
Admission Review Form
| Date added: | 10/05/2010 |
| Filesize: | 462.47 kB |
| Downloads: | 692 |
BHU Provider News
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Quality Improvement Connection A new Performance Improvement-CME activity enables practicing providers with prescribing authority and an active ADHD caseload to make that assessment. Using a HIPAA-compliant, confidential platform, providers...
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Reminder to Behavioral Health Providers The Health Plan considers the PCP to be the gatekeeper of the member's healthcare. In keeping with this premise, providers are responsible not only to treat our members, but to collaborate with the PCP...
Ohio Valley/Mountaineer Region
TF: 1.800.624.6961
Email: hpecs@healthplan.org
Hours: Mon- Fri., 8:30 am to 5:00 pm
HomeTown Region
TF: 1.800.426.9013
Email: hpecs@healthplan.org
Hours: Mon- Fri., 8:00 am to 5:00 pm