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Forms

Access key forms for behavioral health, claims, pharmacy and more.

Behavioral Health

Requests for prior authorization (with supporting clinical information and documentation) should be sent to  ĽOhana 14 days prior to the date the requested services will be performed.

Referral for serious mental illness (SMI) community care services (CCS) program

The DHS 1157, Referral for Serious Mental Illness (SMI) to the Community Care Services (CCS) Program, shall be initiated by the health plan or hospital when there is reason to believe that an applicant/recipient of financial and/or medical assistance may meet the definition of SMI and would meet the criteria to receive services from CCS.

Claims

Pharmacy

This form is used to determine coverage for prior authorizations and medications with utilization management rules.

This form is a prior authorization request for injectable infusions.

This form is to request a medication appeal.

Other Forms

Telemedicine Authorization Request Form

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Last Updated On: 9/2/2015