Behavioral Health

MississippiCAN

Outpatient Treatment Request (OTR) Form

• Outpatient Treatment Request Form (PDF)
• Autism Spectrum Disorders Treatment Form (PDF)
• Outpatient Treatment Request Tip Sheet (PDF)

Psychological Testing Forms

• Inpatient Psychological Testing Authorization (PDF)
• Outpatient Psychological Testing Authorization (PDF)
• Psychological Testing Tips Sheet (PDF)

Electroconvulsive Therapy Form

• Electroconvulsive Therapy (ECT) (PDF)

Intensive Outpatient Program Form

• Intensive Outpatient/Day Treatment Form (PDF)

Injectable Antipsychotics Request for Prior Authorization

• Injectable Antipsychotics Authorization Form (PDF)

Discharge Consultation Documentation

• Discharge Consultation Documentation (PDF)

Allwell from Magnolia Health

Outpatient Treatment Request Form

• Outpatient Treatment Request Form (PDF)

Electroconvulsive Therapy (ECT) Authorization Request Form

Electroconvulsive Therapy (ECT) Authorization Request Form (PDF)

Neuropsychological Testing Authorization Request Form 

• Neuropsychological Testing Authorization Request Form (PDF)