Behavioral Health Outpatient Treatment When complete, please fax to 1 2026

1. Begin by accessing our platform and clicking ‘Get Form’ to open the Behavioral Health Outpatient Treatment document in the editor.
2. Fill in the Member Information section with the member's name, Healthy Connections ID number, address, and contact details. Ensure all fields are completed clearly to avoid processing delays.
3. In the Treating Provider Information section, provide details about the treating provider including their name, license type, NPI number, and contact information. If applicable, indicate if they are in the credentialing process.
4. For the Reason for Services section, specify the primary reason for treatment and requested services along with their frequency. Be sure to include any relevant service codes.
5. Complete the DSM Diagnosis section by listing all relevant diagnoses. Answer questions regarding school services and coordination of care accurately.
6. If applicable, provide reasons for authorization of NON-PAR providers in that designated section.
7. Indicate any prescribed medications and compliance status in the Medications section. List medications and dosages as needed.
8. Attach a current treatment plan detailing progress on goals and any changes made.
9. Finally, use the Additional Comments section for any extra information that may assist in processing your request.

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