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Magellan Health Services

PA HealthChoices

Handbook Supplement opens in a new window (PDF 533K)

Appendices

 
Appendix A
Treatment Authorization Request Cover Sheet opens in a new window (PDF 93K)
Appendix B
Treatment Authorization Request opens in a new window (PDF 20K)
Appendix C
Clinical Review Process opens in a new window (PDF 13K)
Appendix D
Magellan Mental Health Guidelines for HealthChoices opens in a new window (PDF 172K)
Appendix E
Pennsylvania Client Placement Criteria II (PCPC-II) Summary Form opens in a new window (PDF 172K)
Appendix F
Discharge Summary opens in a new window (PDF 21K)
Appendix G
BHRS/RTF Treatment Authorization Request Cover Sheet opens in a new window (PDF 42K)
Appendix H
Life Domain Format Guidelines opens in a new window (PDF 21K)
Appendix I
Plan of Care Summary opens in a new window (PDF 15K)
Appendix J
IPST Sign-In/Concurrence Form opens in a new window (PDF 530K)
Appendix K
Mental Health Services in School Coordination Form opens in a new window (PDF 18K)
Appendix L
Referral for BHRS Services opens in a new window (PDF 19K)
Appendix M
Interagency/Prescriber Collaboration Form opens in a new window (PDF 20K)
Appendix N
Initial Referral for Family-Based Services opens in a new window (PDF 35K)
Appendix O
Alternatives to Residential Mental Health Form, Attachment 8 opens in a new window (PDF 21K)
Appendix P
ECT Request Form opens in a new window (PDF 20K)
Appendix Q
Request for Psychological Testing Preauthorization Form opens in a new window (PDF 30K)
Appendix R
Provider Access Form opens in a new window (PDF 21K)
Appendix S
Cultural Competence Implementation Audit Tool (PDF 30K)
Appendix T
Authorization to Use or Disclose Protected Health Information (PHI) (PDF 35K)
Appendix U
PCP Communication Form opens in a new window (PDF 23K)
Appendix V
Medication Problem Report opens in a new window (PDF 20K)
Appendix W
Adverse Incident Reporting Instructions opens in a new window (PDF 20K)
Appendix X
Provider Adverse Incident Reporting Form opens in a new window (PDF 18K)
Appendix Y
Functional Behavioral Assessment (FBA)/Prescriber Collaboration (PDF 55K)
 
Appendix Z
Children in Substitute Care (CISC) Referral Form (PDF 40K)
 
 
 

Bucks County Specific:

Appendix B1
Bucks County Provider Listing opens in a new window (PDF 34K)
Appendix B2
Bucks County CQC Treatment Authorization Request opens in a new window (PDF 24K)
Appendix B3
Bucks County Comprehensive Interagency Service Plan opens in a new window (PDF 34K)
Appendix B4
Bucks County Updated Comprehensive Interagency Service Plan opens in a new window (PDF 34K)
Appendix BD1
Bucks County and Delaware County Adult ISN Program Description opens in a new window (PDF 79K)
 

Delaware County Specific:

Appendix D1
Delaware County Provider Listing opens in a new window (PDF 300K)
Appendix D2
Delaware County CQC Treatment Authorization Request opens in a new window (PDF 24K)
Appendix D3
Delaware County Interagency Team Form opens in a new window (PDF 24K)
Appendix BD1
Bucks County and Delaware County Adult ISN Program Description opens in a new window (PDF 79K)
 

Lehigh & Northampton County Specific:

Appendix LN1
Lehigh & Northampton Counties Provider Listing opens in a new window (PDF 81K)
Appendix LN2
Lehigh/Northampton County Clinical Review Process opens in a new window (PDF 14K)
Appendix LN3
Lehigh/Northampton Request for Reauthorization -- Family-Based Services opens in a new window (PDF 20K)
Appendix LN4
Lehigh/Northampton IMPACT Program Descriptionopens in a new window (PDF 31K)

Montgomery County Specific:

Appendix M1
Montgomery County Provider Listing opens in a new window (PDF 251K)
Appendix M2
Montgomery County CQC Treatment Authorization Request opens in a new window (PDF 26K)
 
 

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