Forms and Checklists - Driscoll Health Plan

Mental Health and Substance Use Services for Adult Members

Please choose from the Forms and Checklists below

Authorization Process for CPW Case Management Services

Behavioral Health Inpatient Extended Stay Form

Behavioral Health Inpatient Admission Notification Form

Behavioral Health Discharge Summary Form

Bilateral Tubal Ligation with Salpingectomy or Oophorectomy Attestation

Change of Provider Letter Example

CHIP Appeal Request Form

DHP STAR/STAR Kids Appeals Adverse Benefit Decision Flyer

DHP STAR/STAR Kids Appeal Request Form

DHP CCP Prior Authorization Request Form

DHP CCP Prior Authorization Request Form Instructions

DHP PCS Practitioner Statement of Need (PSON)

Provider Forms (envolvevision.com)

Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form

Initial Prior Auth Request for CPW Case Management Services

Inpatient Clinical Review Request Form

Navitus' Prior Authorization Forms

Navitus' Clinical Edit Forms

Non-Emergency Ambulance Prior Authorization Request

OB Attestation for Cystic Fibrosis Screening Form

Outpatient Clinical Request Form

Prior Auth Request for Additional Visits for CPW Case Management Services

Provider Forms (envolvevision.com)

Psychological Testing Prior Authorization Request Form

Texas Authorization Referral Form

Therapy Request Checklist

Therapy Referral Review by Ordering Physician Attestation Form