Mental health inpatient form 2026

1. Click ‘Get Form’ to open the mental health inpatient form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the member's name, ID, address, city, state, zip code, date of birth, phone number, and gender. Ensure all details are accurate to avoid delays.
3. Next, move to the 'Service Provider Information' section. Input the ICD-10 code and details about the service provider including contact person, name, ID/NPI number, address, phone number, and email.
4. In the 'Administrative Information' section, select whether you are making a standard or expedited request. Fill in the service item requested along with dates of service and any codes or units required.
5. Select applicable service types for mental health from the provided options. Make sure to check all that apply.
6. Attach any required documentation as specified for each service type to support your request.
7. Finally, review all entries for completeness and accuracy before submitting your form through our platform.

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