FQHC Behavioral Health Services Provider Manual 2026

1. Click ‘Get Form’ to open the FQHC Behavioral Health Services Provider Manual in the editor.
2. Begin with Section I: Demographic Information. Fill in the Physician or APRN Name, Address, Facility, Telephone, National Provider Identifier Number (NPI), Fax, and Email. Ensure all fields are completed accurately to avoid delays.
3. Proceed to Section II: Allied Professional Update Form. List up to three allied professionals under your supervision. Include their names as they appear on their licenses along with their License Numbers and Expiration Dates.
4. Review the Mental Health Form section. Enter the Beneficiary’s Name, Organization NPI, Medicaid ID #, Date of Birth, Individual NPI, Center’s Name, Service Location Address, and City & State. Complete the DSM-IV TR Diagnosis fields thoroughly.
5. For each clinical information item listed (e.g., Aggression, Depression), circle the appropriate severity level from 0 to 4. This helps in assessing the current state of the beneficiary.
6. Finally, ensure you sign and date where required before submitting your completed forms through our platform for efficient processing.

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