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Forms

Important note: Most forms on this page are in PDF formatting, unless otherwise noted. Please ensure you have the latest version of Adobe Reader on your system. See lower right of this page for a link to additional information.

Optum Forms - Administrative

Benefit Transition Notification

California Grievance and IMR Forms

Clinician Application and Update Forms

Confidential Exchange of Information Form

EAP Member Statement of Understanding Form

Massachusetts Prior Authorization Forms (for State of Massachusetts ONLY)

Member Informed Consent Form (sample)

OHBS-CA Release of Information Form

Optum Release of Information Form

Patient Financial Responsibility Forms

Psychological Testing Request Forms

Site Audit Tools

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

Wellness Assessment Forms * does not apply to Unison membership

Optum Forms - Claims

All outpatient and EAP claims should be submitted electronically via Provider Express or EDI.

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.

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

Inpatient claims are typically submitted on a UB-04 claim form. More information is available about submitting claims on this form at the CMS site.

Claim Inquiry/Adjustment Request Form *does not apply to Unison membership

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

Optum Forms - Clinical

Benefit Transition Notification

California Grievance and IMR Forms

Confidential Exchange of Information Form

Coordination of Care Checklist

Disability Solutions Program Forms

EAP Member Statement of Understanding Form

Florida - FARS and CFARS

Florida Medicaid - Atypical Antipsychotics for Preschoolers - Prior Notification

Fraud, Waste and Abuse (FWA)

Long-Acting Injectable (LAI) Medication

Massachusetts Prior Authorization Forms (for State of Massachusetts ONLY)

Nebraska Medicaid Forms (for State of Nebraska ONLY)

OHBS-CA Release of Information Form

Optum Release of Information Form

Psychological Testing Request Forms

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

Transcranial Magnetic Stimulation (TMS) Forms

        Please use the electronic version above. The fax version is no longer available online.

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

Wellness Assessment Forms * does not apply to Unison membership

Optum Forms - Disclosure

Disclosure Provider Form – Entity  

Disclosure Provider Form – Individual

Disclosure Provider Form – Kansas

Disclosure Provider Form – New Mexico  

 

Minnesota Care Management Center Forms

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

MN Autism and EIDBI Forms and Information

Intensive Outpatient Program Forms

MH TCM

Substance Abuse Forms

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

Medica Behavioral Health Services and Authorization Requirements

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

Psychological Testing Form

Transcranial Magnetic Stimulation (TMS) Initial Request Form