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Provider Behavioral Health Unit Files & 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

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Crisis Encounter Report Crisis Encounter Report

Date added: 12/12/2007
Filesize: 541.24 kB
Downloads: 83

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.

Psychological Testing Pre-Authorization Request Psychological Testing Pre-Authorization Request

Date added: 01/18/2008
Filesize: 613.72 kB
Downloads: 90

This form is to be used for the Behavioral Health Unit.

Treatment Continuation Request Treatment Continuation Request

Date added: 07/02/2009
Filesize: 1.12 MB
Downloads: 149

This new and improved form is to be used for the Behavioral Health Unit.

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

 

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