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Mental Health Applications

Eating Disorder Checklist

The eating disorder checklist provides a list of required documentation that must be submitted for a beneficiary requesting eating disorder services. Attach this documentation to your online request or fax it along with the Inpatient TRICARE Service Request/Notification form to 1-844-818-9289.

  • Created: Dec 5, 2018
  • Modified: Dec 5, 2018
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Eating Disorder Treatment Concurrent Review Form

When requesting a prior authorization for continued eating disorder treatment, a completed Eating Disorder Concurrent Review form must be submitted. Attach this completed form to your online request or fax it along with the Inpatient TRICARE Service Request/Notification form to 1-844-818-9289.

  • Created: Dec 31, 2018
  • Modified: Dec 27, 2018
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Application for Residential Treatment Center – Provider

This application must be completed in its entirety by the referring provider when residential treatment center (RTC) placement is requested. Attach this completed form along with the Family RTC application to your online request or fax it along with the Inpatient TRICARE Service Request/Notification form to 1-844-818-9289.

  • Created: Dec 5, 2018
  • Modified: Dec 5, 2018
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Application for Residential Treatment Center – Family

This form must be filled out by the beneficiary (the parent or legal guardian) in order to have a child placed in a Residential Treatment Center. Health Net Federal Services, LLC will look at the request once we receive both the family application and the Provider RTC Application. Attach this completed form to your online request or fax it along with the Inpatient TRICARE Service Request/Notification form to 1-844-818-9289.

  • Created: Jul 22, 2014
  • Modified: Dec 5, 2018
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Residential Treatment Center (RTC) Concurrent Review

When requesting a prior authorization for continued residential treatment center care, a completed Residential Treatment Center (RTC) Concurrent Review form must be submitted. Attach this completed form to your online request or fax it along with the Inpatient TRICARE Service Request/Notification form to 1-844-818-9289.

  • Created: Jul 1, 2015
  • Modified: Dec 5, 2018
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Request for Extension of Mental Health Services

When requesting an extension of mental health services, providers should complete the Request for Extension Form and submit along with supporting clinical information. Attach this completed form to your online request or fax it along with the Inpatient TRICARE Service Request/Notification form to 1-844-818-9289.

  • Created: Oct 19, 2016
  • Modified: Dec 5, 2018
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Partial Hospitalization Program (PHP)/Intensive Outpatient Program (IOP) Concurrent Review

When requesting a prior authorization for a continued partial hospitalization program or intensive outpatient program, a completed concurrent review form must be submitted. Attach this completed form to your online request or fax it along with the Inpatient TRICARE Service Request/Notification form to 1-844-818-9289.

  • Created: Dec 5, 2018
  • Modified: Dec 5, 2018
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