Healthy Blue - Healthy Connections

Outpatient Mental Health Treatment

Use these forms to request certification for outpatient mental health treatment services (e.g. individual or group therapy). Do not use these forms for services related to substance use disorder (SUD), intensive outpatient programs (IOP) or partial hospitalization programs (PHP). Please use the psychological testing form below.

Choose a Form

• Outpatient Mental Health Treatment Request

  Use this form for authorization of Individual Therapy, BMOD, Community Integration Services, ACT services, TCS, Autism Services, PRS, FS, Medication Management, Family Therapy, Intensive In-Home Treatment and Group Therapy.

• Psychological/Neuropsychological Testing Preauthorization Request

  Use this form to request psychological/neuropsychological testing.