Forms

Provider Form Download Area

Please click on the form you require. Print and fill out form. Send completed form to our secure clinical fax at:

713-781-4954.

Adobe Acrobat is required to download the files on this page. You may download it for free by clicking on the link below:

Get Adobe Reader Here

CPT Code Change Information
Changes to CPT Codes for 2013Click Here
Changes to CPT Codes for 2013 FAQClick Here

Misc Provider / Facility Form Downloads
Application- Individual Provider. (All therapists: Please download the PIP Questionnaire listed below)Click Here
Application-FacilityClick Here
Clinical Feedback FormClick Here
Refer your Psychiatrist / TherapistClick Here
General Release of InformationClick Here
Provider Demographic Data Change FormClick Here

Provider Manual Download Area
IntroductionClick Here
General Release of Information IBHClick Here
Refer Your Provider IBHClick Here
Pre-certification – Authorization of TreatmentClick Here
Adverse DeterminationClick Here
Other ServicesClick Here
Billing ProceduresClick Here
FormsClick Here
W-9Click Here

For more information or a customized quote please contact us at:2424 Wilcrest Dr. | Suite 230 | Houston, TX 77042
Toll Free: (800) 324-4327