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

Credentialing Forms
Application- Individual ProviderClick Here
Application-FacilityClick Here
Refer your Behavioral Health ProfessionalClick Here
General Release of InformationClick Here
Provider Demographic Data Change FormClick Here
E-Counseling Attestation FormClick Here
W-9Click Here

Provider Manual Download Area
IntroductionClick Here
Pre-certification – Authorization of TreatmentClick Here
Adverse DeterminationClick Here
Other ServicesClick Here
Billing ProceduresClick Here
EAP Authorization Billing Form SampleClick Here
Clinical Feedback FormClick 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