BH Forms

Inpatient and Residential Treatment for Substance Use Disorder (SUD)

• Discharge Consultation Documentation (PDF)
  
• Initial Assessment Form for Substance Use Disorder Treatment Admission (PDF)
• Reassessment Form for Continued Substance Use Disorder Treatment (PDF)
• Residential/Inpatient Substance Use Disorder Treatment Prior Authorization Request Form (PDF)

Outpatient Treatment Request (OTR) Form

• Applied Behavioral Analysis Treatment OTR (PDF)
• IN Medicaid ABA Provider Request Tip Sheet (PDF)
• Intensive Outpatient Day Treatment Form (PDF)
• HHW/HIP Outpatient Treatment Request (OTR) Form (PDF)