Form Guidelines and Form Set

The following forms and guidelines are recommended for organizing charts to meet all documentation requirements.

Forms which can be modified for individual offices are available as Microsoft Word documents, all other forms require Adobe Acrobat.

Universal Form Set

The following forms may be used for all health plans.  Required forms are bolded.  The remaining forms are provided as examples, which meet contract requirements for treatment record documentation.

NEW:     Treatment Record Tips

New Patient Forms

Psychiatry Only:

Continued Treatment Forms

Claims Forms

Spanish Forms

Health Plan Specific Guidelines and Resources

Aetna Behavioral Health

www.aetna.com

Health Net - Managed Health Network

www.mhn.com

Pacificare Behavioral Health

United Behavioral Health

www.ubhonline.com

Talbert Medical Group

www.talbertmedical.com

CHIPA Contact Numbers:


800-779-3825

562-467-5555

CHIPA Fax Numbers:

562-402-2666

888-659-7921


Providers
Request Additional Authorization
CHIPA Guidelines and Form Set
CHIPA Policies & Procedures
Provider Application
Provider Newsletters
   

 
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