Authorization Guides, Forms & Fee Schedules

Guides

2018 Regional Practice Guidelines

Suboxone Film Criteria

Forms

Daily Withdrawal Management Summary Form

Health Share Pathways LOC Treatment Authorization Request (HSTAR) Form

Health Share Pathways LOC Treatment Authorization Request (HSTAR) Form – PDF

Health Share Pathways PA Treatment Authorization Request (HSTAR) Form

Health Share Pathways PA Treatment Authorization Request (HSTAR) Form – PDF

New Practitioner Add Form 

Nursing Assessment Form

Provider Address Relocation and Addition Form

Provider Administrative Address Update Form

Referral Form A - Initial Assessment for Applied Behavioral Analysis (Diagnosing Providers Only)

Referral Form B - Request for ABA Treatment (ABA Providers Only)

Behavioral Health Non-Formulary MAT Prior Authorization Request Form

Substance Use Disorder Residential Treatment - Authorization / Re-Authorization Form

Timely Filing Waiver Request Form

Fee Schedules

Mental Health Fee Schedule (Effective 07.1.2018)

Substance Use Disorder Fee Schedule (Effective 7.1.18) 

Questions

Health Share Contracting & Provider Network Assistant
(971) 334-8056
providers@healthshareoregon.org