Health Care Provider Forms

Medical Policy Forms (Note: May be used as a supplement to medical record documentation)

Description

Behavioral Health/Mental Health Forms for ERS Participants

Description

Select Link for list of forms

Behavioral Health/Mental Health Forms for TRS Participants

Description

Select Link for list of forms

Behavioral Health for Texas Medicaid Plans

Texas Medicaid Behavioral Health forms

Behavioral Health for Other BCBSTX Plans

(Note: for ERS or TRS participants or Medicaid Members refer to specific form links above)

Applied Behavior Analysis (ABA) forms:

• ABA Clinical Service Request Form
• ABA Initial Assessment Request
• ABA Change Notification Form
• Supervision via Telehealth Request – Attestation

Pharmacy

Description

Express Scripts ® Pharmacy Mail Order: ePrescribe new prescriptions to EXPRESS SCRIPTS HOME DELIVERY or call 888-327-9791 for faxing instructions

Fax forms must be faxed from a physician's office

Specialty pharmacy drugs fax form for general use

Specialty pharmacy drugs fax form by drug therapy

Request to override the dispensing/quantity limit

Topical Verapamil Override Request Specialty pharmacy drugs fax form for general use

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