e-Referral - Care Management Forms

Care Management Forms

Below are links to forms used to request authorization for various services. These forms are also available, along with others, on the web-DENIS Forms page. To access the complete Forms Library, log in to web-DENIS > BCN Provider Publications and Resources > Forms.

Bariatric surgery

Physician Supervised Weight Loss Program Procedure (PDF)
Bariatric Surgery Assessment Form: Patient Referral Information (PDF)
Physician Supervised Weight Loss Program Documentation form (PDF)

Behavioral health services

Behavioral Health 2010 Continuing Outpatient Authorization Request Form (PDF)
Behavioral Health Initial Outpatient Authorization Request Form (PDF)
Behavioral Health Outpatient Treatment Authorization (PDF)
Behavioral Health Inpatient Concurrent Review Form (PDF)
Behavioral Health Medication Management Registration Form (PDF)

Drugs paid under medical benefit

Immune Globulin Replacement Therapy (IVIG, SCIG) (PDF)

e-referral

e-referral Application form – Sign up for e-referral (PDF)
Change form – Add or delete providers or users (PDF)
Change form for billing services and service bureaus – Request group ID changes (PDF)

Sleep study authorization sample questionnaire

When requesting authorizations for sleep studies on e-referral, the system will prompt the submitter to complete a questionnaire to determine the appropriateness of the request.

Sample questionnaire (PDF)

e-referral Resources

Care Management Resources

Additional Resources

Care Management Forms