Authorization Guides, Forms & Fee Schedules

Guides

2017 Regional Practice Guidelines

Suboxone Film Criteria

Vivitrol Criteria

Forms

Daily Withdrawal Management Summary Form

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

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

Nursing Assessment Form

Medication Assisted Treatment (MAT) Request Form

Substance Use Disorder Withdrawal Management (Detox) Request Form

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

Timely Filing Waiver Request Form

Fee Schedules

Mental Health Fee Schedule (July 2017)

Substance Use Disorder Fee Schedule (July 2017)

 

Questions

Health Share Contracting & Provider Network Specialist
(503) 416-3972
providers@healthshareoregon.org