Behavioral Health

Medicare

• Medicare BH PA Form - Inpatient (PDF) 
• Medicare BH PA Form - Outpatient (PDF)

Medicaid

• Medicaid BH PA Form - Inpatient (PDF)
• Medicaid BH PA Form - Outpatient (PDF)
• OR Medicaid Certificate of Need Form (CON) (PDF)

For behavioral health services only: Discharge information is required within 24 hours of discharge from IP or RTC levels of care. Please fax discharge clinicals to: 833-505-1300.