Humana Military Healthcare Services Behavioral Health Forms

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Behavioral Health Forms

This page enables medical providers to access the forms needed when administering Behavioral Healthcare to TRICARE beneficiaries residing the South region.

You will need Adobe® Reader® to view the Behavioral Health files outlined below. If you do not have this program, click on the Adobe image below to download it for free.

Adobe PDF Format Forms

Appointment of Representative

Authorization for Release of Information

Case Management Behavior Health Referral Form

Clinical Expertise/Specialties

Consult Report Form

ECT Request Form

Letter of Referral

Non-Covered Services Waiver Form

OP Substance Abuse Rehab Group Therapy Request

Outpatient Treatment Report

Provider Address Change

Psych and Neuro Psych Testing

Residential Treatment Center Application

Retro Outpatient Treatment Report

TRICARE Dental Anesthesia Facility Prior Authorization Request

TRICARE Higher Level of Care Treatment Report

TRICARE Higher Level of Care Treatment Report (RTC Only)

Waiver of Benefit Request - In Patient

Waiver of Benefit Request - Psych-PHP

Waiver of Benefit Request - RTC

Waiver of Benefit Request - Substance Abuse

Please note forms will start to download when selected. Click on form desired. If your browser does not start downloading, RIGHT-click on form and choose "Save As". Downloading may take 45 seconds to a minute depending on the size of the form selected, along with your connection speed.

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Last Update: April 24, 2008