Authorization Guides, Forms & Fee Schedules

Guides

2018 Regional Practice Guidelines

Suboxone Film Criteria

Forms

Daily Withdrawal Management Summary Form

Referral Form A - Initial Assessment for Applied Behavioral Analysis (Diagnosing Providers Only)

Referral Form B - Request for ABA Treatment (ABA Providers Only)

Nursing Assessment Form

Regional Prior Authorization (PA) Request Form

Substance Use Disorder Withdrawal Management (Detox) Request Form

Substance Use Disorder Residential Treatment - Authorization / Re-Authorization Form

Timely Filing Waiver Request Form

Fee Schedules

Mental Health Fee Schedule (January 2018)

Substance Use Disorder Fee Schedule (February 2018)

 

Questions

Health Share Contracting & Provider Network Assistant
(971) 334-8056
providers@healthshareoregon.org