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:


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

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

Credentialing Forms
Application- Individual Provider Click Here
Application-Facility Click Here
Refer your Behavioral Health Professional Click Here
General Release of Information Click Here
Provider Demographic Data Change Form Click Here
E-Counseling Attestation Form Click Here
W-9 Click Here

Provider Manual Download Area
Introduction Click Here
Pre-certification – Authorization of Treatment Click Here
Adverse Determination Click Here
Other Services Click Here
Billing Procedures Click Here
EAP Authorization Billing Form Sample Click Here
Clinical Feedback Form Click 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