Virginia Authorization Forms

Plans administered by Optum behavioral do not require prior authorization for routine outpatient services. For Virginia CCC Plus or Medallion 4.0, see specific section below. If you need authorization for any of the following services, please select the link below:

ABA Assessment & Treatment Plan Forms

ABA Assessment Requests - electronic submission (commercial ABA providers only)
ABA Treatment Plan - electronic submissions
To download, click DMAS VA MHS Forms

VA MHS Request Form

VA MHS Request Form - electronic submission

Psychological Testing Request Forms

Optum Psych Testing Request Form - electronic submission

Transcranial Magnetic Stimulation (TMS) & Electroconvulsive Therapy (ECT) Forms

TMS & ECT Authorization Request Form (NEW) - electronic submission

Virginia CCC Plus or Medallion 4.0 ARTS Service Registration and Authorization Forms

To ensure timely processing, please make sure your request meets all of the following criteria:

> You are using a current DMAS form for the specified service

> The member is a current eligible member of the CCC Plus or Medallion 4.0 Plans

> The services being requested are for ARTS

> There is only one member/one service per fax

> All information is complete and legible

You will be mailed a confirmation letter with an authorization number.

To download, click DMAS ARTS Forms

All ARTS forms can be faxed to (855) 368-1542, or follow specific online submission instructions. For questions, call (877) 843-4366.