Authorization Guides, Forms & Fee Schedules

Guides

2018 Regional Practice Guidelines

Suboxone Film Criteria

Forms

Daily Withdrawal Management Summary Form

Health Share Treatment Authorization Request for Higher Level of Care (HSTAR_LOC): PDF ; Word

Health Share Treatment Authorization Request for Prior Authorization (HSTAR_PA): PDF ; Word

SUD 3.7 Medically Monitored Residential Authorization Request Form: PDF ; Word

SUD Day Treatment Authorization Request Form: PDF ; Word 

SUD Residential Authorization Request Form: PDF ; Word

SUD Residential Dual Diagnosis Authorization Request Form: PDF ; Word

Pathways Provider Address Addition Form: PDF ; Word

Pathways Provider Address Relocation Form: PDF ; Word

Pathways Provider Administrative Address Update Form: PDF ; Word

Adding New Practitioner to an Organization Form: PDF ; Word

Pathways Provider Billing Data Change Form: PDF ; Word

Request Addition of Contracted Service Form: PDF ; Word

LOC Adult Initial Tx Reg Form: PDF ; Word

LOC Adult Continuted Stay Tx Reg Form: PDF ; Word

LOC Child & Adolescent Initial Tx Reg Form: PDF ; Word

LOC Child & Adolescent Continued Stay Tx Reg Form: PDF ; Word

ABA Referral Form A_Initial Assessment: 

ABA Referral Form B_Request for Treatment:

Daily Withdrawal Management Summary: PDF ; Word

Health Share Nursing Assessment: PDF ; Word

Regional PA MAT Request Form: PDF ; Word

Timely Filing Waiver Request: PDF ; Word 

CIM Provider Tools: PDF

CIM Access Request Form: Word


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

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

Non-Formulary MAT Prior Authorization Request Form: PDF ; Word

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

Fee Schedules

Mental Health Fee Schedule (Effective 09.1.2018)

Substance UseDisorder Fee Schedule (Effective 9.1.18)


Questions

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