Behavioral Health Forms

• Behavioral Health Provider Service Check List
  This form helps HIP identify the participating health care provider's service, billing and correspondence addresses, as well as the types of services the practice offers and the professional demographics of the office staff.
• Behavioral Health Consultation
  Use this form to notify the member's PCP of recommendations for a member's health care and follow-up treatment as well as of diagnostic impressions of the member's health state.
• Behavioral Health Consultation Follow-Up
  This form is used to notify the member's PCP of the outcomes of a member follow-up visit performed by the behavioral health clinician.
• Behavioral Health Request for Physical Exam Status
  This form requests that the PCP provide the behavioral health clinician with the findings of the member's physical exam, if performed in the past year. Or, if a physical exam has not been conducted during this time, it requests that the PCP conduct a physical exam and provide the findings.
• Authorization to Use and Disclose Protected Health Information
  This document is used to authorize the release and disclosure of protected health care information pertaining to an individual by the same individual to a third party in the manner therein specified.
• Authorization to Use and Disclose Psychotherapy Notes
  This form authorizes the release and disclosure of psychotherapy notes pertaining to an individual by the same individual to a third party in the manner specified on the form.
• Informed Consent to Perform an HIV Test
  The New York State Department of Health (NYSDOH) is urging providers of HIV counseling and testing to utilize this form when providing HIV testing services.

For assistance in filling out any of the forms, call your HIP Representative.

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