Behavioral Health
- Behavioral Health Supplement (PDF)
- Contact us:
- Keystone First – CHIP Behavioral Health Enrollee Line: 1-844-524-2447
- Keystone First – CHIP Behavioral Health Provider Line: 1-877-244-7124
- Keystone First – CHIP Behavioral Health
Email: DLPCPerformCareCHIPBehavioralHealth@performcare.org
Behavioral health forms
- Behavioral Health Provider Data Update Form (PDF)
- Child/Adolescent Services Request Submission Sheet (PDF)
- Electroconvulsive Therapy (ECT) Outpatient Prior Authorization Request Form (PDF)
- Intensive Behavioral Health Services (IBHS) ABA Assessment Registration Form (PDF)
- Intensive Behavioral Health Services (IBHS) ABA Proposed Treatment Plan (PDF)
- Intensive Behavioral Health Services (IBHS) ABA Provider Choice Acknowledgment Form (PDF)
- Intensive Behavioral Health Services (IBHS) ABA Written Order Form (PDF)
- Intensive Behavioral Health Services (IBHS) Discharge Summary Form (PDF)
- Intensive Outpatient (IOP) Discharge Summary (PDF)
- Mental Health Intensive Outpatient (IOP) Prior Authorization Request (Initial) (PDF)
- Mental Health Intensive Outpatient (IOP) Prior Authorization Request (Reauthorization) (PDF)
- Mental Health Out-of-Network (OON) Service Prior Authorization Request Form (PDF)
- Out-of-Network (OON) General Information Form (PDF)
- Psychological and Neuropsychological Testing Request Form (PDF)
- Psychologist Attestation Form (PDF)
- Psychiatrist Attestation Form (PDF)
- Substance Use Disorder Intensive Outpatient (IOP) Prior Authorization Request Form (PDF)
- Substance Use Out-of-Network (OON) Service Prior Authorization Request Form (PDF)
- Transcranial Magnetic Stimulation (TMS) Outpatient Prior Authorization Request Form (PDF)