Mental Health Provider
The ICD-10 Prioritized List can be found at the following webpage: http://www.oregon.gov/oha/herc/Pages/ICD-10-List.aspx
- 2015 Practice Guidelines (Medical Necessity Criteria)
- Medical Necessity addendum - CATC admission (34 KB)
- 2015 OHA Specifications Follow Up After Hospitalization for Mental Illness
Mental health reporting forms
Mental health provider contract exhibit forms
- Invoice Template - Exhibit 6A (you may request an excel version of the invoice by emailing MHASD business services at: email@example.com)
- Cost Reimbursement Budget - Exhibit 6C
Mental health treatment request forms
Wraparound / Integrated Service Array forms - Updated July 2015
Please use the following revised forms when making a Wraparound or ISA referral. This checklist is a handy guide to ensure the packet is complete. Submitting an incomplete packet will delay the eligibility determination process. Our Referral Coordinators are happy to assist with the process, so please feel free to call them at 503-988-4161. Once the referral packet is complete and includes forms signed by the parent/guardian, fax it to the intake fax at 503-988-3328.
Forms Required for both ISA and Wraparound Referrals
1. Referral Form
2. Consent for Care Coordination
3. Authorization to Release Information (Please include a separate one for each contact/organization (ex. Parents, school, DHS caseworker, DD caseworker, etc.)
4. Copies of information from all referring parties involved in the care of the client/family that is pertinent to determining Wraparound/ISA eligibility (ex. IEP, clinical records, assessments, psychological or psychiatric evaluation).
Additional Forms Required for Wraparound Only Referrals
1. Release of Authorization to the Wraparound Review Committee
2. Typed Wraparound Review Committee Presentation Format
3. A copy of Comprehensive Mental Health Assessment, Psychological or Psychiatric Evaluation completed within the past 12 months.
Additional Forms Required for ISA Only Referrals
1. A copy of a Comprehensive Mental Health Assessment, Psychological or Psychiatric evaluation completed within the past 60 days.