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.
This page includes sample and actual forms Magellan uses or requires in the member’s medical record. Where indicated, forms may be printed and photocopied as needed for the Magellan members in your care.
NOTE: Forms marked “SAMPLE” may not be compliant with some state regulations. It is the provider's responsibility to ensure that his/her documentation is compliant with all applicable state laws.
Treatment Record Review
The Treatment Record Review form is not required in the member's file. This form is used by Magellan reviewers when evaluating treatment records during a site visit and is posted for reference purposes only. For more information on treatment record reviews and site visits, please see the Magellan Provider Handbook.
Authorization to Disclose PHI to PCP
This is a sample Authorization to Disclose PHI to PCP form that enables the behavioral health provider to share protected health information (PHI) with the primary care physician (PCP). The provider is encouraged to have each member sign and date the form at the outset of new episodes of care.
Clinician Communication Form
A completed Clinician Communication Form 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 his or her first appointment; then sign and have the member sign, and retain a copy in the member's record.
- Member Rights and Responsibilities -- English
- Member Rights and Responsibilities -- Spanish
- Medicaid Enrollee Rights and Responsibilities -- English
- Medicaid Enrollee Rights and Responsibilities -- Spanish
Psychological Testing Form for electronic completion/saving
Psychological Testing Form for handwritten completion
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 an authorization has been received.
Treatment Request Form
Note that most plans Magellan manages do not require authorization for routine outpatient services; call the number on the member's benefit card if you have questions about plan requirements.
If a treatment request form (TRF) is required by the member's plan for authorization of additional outpatient treatment, we strongly encourage you to use our secure, Internet-based TRF (After signing in, choose “Get More Outpatient Authorizations” from the “Providing Care” top-menu item). Most providers use this method to submit TRFs due to the ease of transmission and rapid response. However, since some providers still prefer to submit paper TRFs by fax, we want to provide the above form that you may print out as well. You can use this TRF for most members; but, there are some exceptions to using the form.
An authorization number is required to submit a TRF. To obtain an authorization form, sign in to your secure account and choose "Request Outpatient Authorization" from the left-hand menu, then select "Start New OP Auth."
Auxiliary Forms (use as needed)
Substance Abuse/Chemical Dependency Assessment
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.
This optional tool can be used to assist in the assessment of client depression.