Authorization for the Release of Information
Rev. 06-06-2006
This form is to be completed by members who wish to allow other
individuals to receive information about their medical or claims
records.
Outpatient Treatment
Rev. 06-06-2006
Providers should use this form when developing an outpatient
treatment program for their patients.
Patient
Registration form
Rev. 06-06-2006
Providers should use this form to register a patient within the
BHC system.
Physician Certificate of Responsibility
Rev. 10-01-03
Providers choosing
to send claims electronically to BHC through a third party intermediary or
clearinghouse must complete a sign a Physician Certificate of Responsibility.
Request for Psychological Testing
Rev. 03-19-02
Providers should use this form to request psychological testing for a patient.
Trading Partner Agreement
Rev. 06-06-2006
Providers choosing to send claims electronically to BHC must first complete
and sign a Trading Partner Agreement (TPA).
Change
of Information Notification
Rev. 06-06-2006
Providers should use this form to notify BHC of any additions, deletions or
changes to: physical, mailing or billing addresses, tax ID numbers, or
contact information.
