Clinical Forms
In support of our commitment to quality care, we require our providers to maintain organized, well-documented member treatment records that reflect continuity of care. We expect providers to document all aspects of treatment in a timely manner, including face-to-face encounters, telephone contacts, clinical findings and interventions.
NOTE: Forms may not be compliant with some state regulations. It is the provider's responsibility to ensure that their documentation complies with all applicable state laws.
Treatment Record
- Informed Consent for Treatment (PDF)
- Initial Evaluation (PDF)
- Progress Note (PDF)
- Treatment Plan (PDF)
- Discharge Summary (PDF)
This Treatment Record Review tool (PDF) is not required in the member's file; however, it is is used by Magellan reviewers when evaluating treatment records during a site visit, so we've posted for your reference. For more information on treatment record reviews and site visits, see the Magellan Provider Handbook (PDF).
Clinician Communication Form
A completed Clinician Communication Form (PDF) allows the behavioral health provider to inform the PCP that behavioral health treatment is occurring, and also provides information on how to contact the behavioral health provider if needed. Other information in the communication can include member diagnosis, a clinical summary, treatment plan changes, member safety issues, laboratory tests ordered, and medication issues or changes.
Member Rights and Responsibilities
Review the rights and responsibilities statement with the member at their first appointment; then sign and have the member sign, and retain a copy in the member's record.
- Member Rights and Responsibilities -- English (PDF)
- Member Rights and Responsibilities -- Spanish (PDF)
- Medicaid Enrollee Rights and Responsibilities -- English (PDF)
- Medicaid Enrollee Rights and Responsibilities -- Spanish (PDF)
Psychological Testing Request Form
Complete this form to request authorization for psychological testing. In most cases, an initial assessment by a behavioral healthcare provider must be administered before psychological testing is authorized. To avoid potential issues with reimbursement, do not initiate psychological testing until you have received authorization.
- Sign in to this website and use the Request Member Care application to enter psychological testing preauthorization requests online (available for some plans)
- Psychological Testing Preauthorization Request Form (PDF) for handwritten completion
- Psychological Testing Form Instructions (PDF)
- California providers: visit our California webpage for forms to use in your state.
The fax number for form submission differs by member plan; call the customer service number on the member’s insurance ID card to learn the appropriate fax number.
ABA Forms
For autism-related forms, sign in to this website. From the Resources section, select State & Plan Information, then choose Autism-Specific Information.
Auxiliary Forms (use as needed)
Substance Abuse/Chemical Dependency Assessment (PDF)
If your assessment or the result of the chemical dependency (CD) screening indicates a possible CD issue, the Substance Abuse/Chemical Dependency Assessment form must be completed. This form documents that you have conducted a CD assessment.
Depression Screening (PDF)
Use this optional tool to assist in the assessment of client depression.
Plan- or State-Specific Forms
Refer to the plan- and state-specific pages of this website.