Resources

Medical Necessity addendum - CATC admission (34 KB)
School Transition Protocol Packet 2.2017 (199.53 KB)

Reporting Forms

Critical Incident Report form (380 KB)
Client Enrollment Form for Culturally Specific Provider Agencies (19.47 KB)
Crisis Alert Form (40.5 KB)

Complaint Forms

For Oregon Health Plan members and non-members»

Contract Exhibit Forms

For providers who have a Multnomah County Mental Health & Addiction Services Division cost reimbursement contract:

Invoice Template Contract Exhibit 6A (69.36 KB)
To request an Excel version, email mhasd.businessops@multco.us

Cost Reimbursement Budget - Contract Exhibit 6C (44.7 KB)

Mental Health Treatment Request Forms

MMH Treatment Authorization Request (TAR) Form (21.97 KB)
MMH Psychological Testing Authorization Request (PTAR) Form (31.49 KB)

Psychological Testing Authorization Request (PTAR) form instructions:

To request a psychological evaluation, please complete a PTAR form and submit supporting clinical documentation.

You must include the following:

     1. PTAR with completed supplemental questions. 
     2. Mental health assessment (within last 60 days); updated treatment plan and needs.
     3. Submit any additional clinical justification and documentation to support request for authorization. 

Submit your request to Multnomah Mental Health Utilization Review by secure email to URTeam@multco.us or by fax, 503-988-3137.

*Neuropsychological assessments or assessments related to medical conditions are the responsibility of member's capitated medical plan. Requests must be made through the patient's medical insurance, not behavioral/mental health.


State and Health Share/Multnomah Mental Health Contracts

County Financial Assistance Agreement 2017-2019 (1.32 MB)
AMHI Agreement 2017 - 2019 (217.57 KB)
Health Share of Oregon CCO 2019 contract (2.71 MB)