Minnesota Authorization Forms
MN Care Advocate’s Fax # is 1/855-454-8155
MN Autism and EIDBI Forms and Information
Intensive Outpatient Program Forms
MH TCM
- TCM Powerpoint Presentation
- TCM Authorization Form
- MBH TCM Need for DTR Notification
- MBH TCM DTR Letter
- Medica Member Appeal Rights
- MBH TCM Discharge Criteria
Psychological Testing Request Forms
- Medica Psych Testing Request Form - (PDF download)
- Optum Online Psych Testing Request Form - Non-Medica
Substance Abuse Forms
- Medication Assisted Treatment (non-methadone) Request Cover Sheet
- Methadone Maintenance Assessment Cover Sheet
- Substance Abuse Retrospective Request Form
- Substance Abuse Service Request Cover Sheet
Other Authorization Request Forms
- Appointment of Representative Form
- Assertive Community Treatment (ACT) Form (for non-contracted providers only)
- DBT Request Form (for non-contracted providers only)
- Intensive Community Based Services (ICBS) Form
- Intensive Community Based Services (ICBS) Monthly Update Form
- MEDICA® Medicare Behavioral Health Quick Reference Guide
- Mental Health Retrospective Request Form - Medica Behavioral Health - MN CAC
- Psychological Testing Form
- Transcranial Magnetic Stimulation (TMS) & Electroconvulsive Therapy (ECT) Initial Request Forms