SERVICE REQUEST FORMS
The following forms are for services requiring a pre-authorization. Please complete and submit the request before providing the service to a member.
Service Request Form Demo Video
Please view the following video for a demonstration of how to fill out the new Service Request Form, using the Adult CBRS form for demonstration purposes. Please note that the video will play the most clearly on Firefox, or the newest version of Internet Browsers.
Case Management Service Request Form
CBRS Adult Service Request Form
CBRS Child Service Request Form
Crisis Services Request Form
Extended Psychotherapy Service Request Form
Family Support Service Request Form
Initial Intensive Outpatient Program (IOP) Service Request Form
Continuing Intensive Outpatient Program (IOP) Service Request Form
Partial Care Service Request Form
Peer Support Service Request Form
Below are other forms that may be of assistance in helping Optum Idaho members.
All of the PDFs below will open in a new window
- Early Periodic Screening Diagnosis and Treatment Form (491.11 KB)
- Field Care Coordination Referral Form (93.39 KB)
This indicates that you are leaving our site and these links to others sites are for informational purposes only.
Provider Clinical Questions: (855) 202-0983 | PCP Psychiatric Consult press option 1