Administrative Forms
- Gambling Provider Registration Form (PDF)
- Authorization to Disclose Substance Use Treatment Information For Coordination Of Care (PDF)
- Basis-24 EULA (PDF)
- BHA Appeal Form (PDF)
- Concurrent PRP Clinical Worksheet (PDF)
- Cover Letter EULA (PDF)
- Documentation for Uninsured Eligibility Benefit (PDF)
- Initial Precertification PRP Clinical Worksheet (PDF)
- Intermediary Authorization Form (PDF)
- Maryland Additional User Account Request Form (PDF)
- Maryland Additional User Account Request Form for Multiple Users (PDF)
- Provider Account Request Form (PDF)
- ProviderConnect Multiple Matching Records Resolutions Form (PDF)
- Psychological Testing Form (PDF)
- ProviderConnect Users Agreement (PDF)
- Release of Information (ROI) for MCO's Updated - Optum (PDF)
- Release of Information/Authorization for Disclosure (English) (PDF)
- Release of Information/Authorization for Disclosure (Spanish) (PDF)
- Request for Reimbursement for non-Medicaid Services (PDF)
- Uninsured Registration Form (PDF)
- Beacon Health Options Timely Filing Waiver for Retroactive Eligibility (PDF)
- VO Release of Information - DORS (PDF)
Clinical Forms
- ASAM Six Dimensions Clinical Information (PDF)
- Outpatient Concurrent Review Form (PDF)
- TBS Referral Form (DOC)
- TCM/1915(i) Referral Forms (DOCX)
- Residential Treatment Continued Stay Request Form - RTC (PDF)
- Request for Repetitive Transcranial Magnetic Stimulation (PDF)
- Additional forms are available (external link)
Outcome Measurement System (OMS)
State and federal governments are requiring Public Behavioral Health Systems to collect outcome data regarding each participant who receives services. In Maryland, specific information regarding the treatment outcomes for individuals from 6 to 64 years old will be collected from Outpatient Mental Health Centers (OMHCs), Federally Qualified Health Clinics (FQHCs), and Hospital-based clinics.
Participant outcomes regarding the management of their illnesses and the quality of their lives are the most important measures of the benefit provided by services in the Public Behavioral Health System. In addition, information about outcomes of mental health services is a key element to supporting the recovery and resiliency of participants (along with access to appropriate services, active participant participation in treatment decisions, and a recovery culture) because knowledge about what treatments are effective is empowering and engenders hope.
COMAR 10.09.70.07 permits the Behavioral Health Administration to establish the process for pre-authorization of services.
OMS Tools
- OMS Interview Guide Reference Sheet, Version 3, December 13, 2014 (PDF)
- OMS Interview Guide, Version 3, December 13, 2014 (PDF)
- Adult Questionnaire, Version 3 – December 13, 2014 (PDF)
- Adult Questionnaire Response Cards Version 3 – December 13, 2014 (PDF)
- Adult Discharge Form – Client Not Participating, Version 3 – December 13, 2014 (PDF)
- Child and Adolescent Questionnaire, Version 3 – December 13, 2014 (PDF)
- Child and Adolescent Questionnaire Response Cards, Version 3 – December 13, 2014 (PDF)
- Child and Adolescent Discharge Form – Child, Adolescent, Caregiver Not Participating, Version 3 – December 13, 2014 (PDF)
- Discharge Information Sheet, Version 3 - December 13, 2014 (PDF)