Behavioral Health

MississippiCAN

Outpatient Treatment Request (OTR) Form

• Outpatient Treatment Request Form (PDF)
• Outpatient Treatment Request Tip Sheet (PDF)

Inpatient Treatment Request  (ITR) Form

• Inpatient Treatment Request Form (PDF)

Injectable Antipsychotics Request for Prior Authorization

• Injectable Antipsychotics Authorization Form (PDF)

Discharge Consultation Documentation

• Discharge Consultation Documentation (PDF)

Wellcare

Outpatient Treatment Request Form

• Outpatient Treatment Request Form (PDF)

Electroconvulsive Therapy (ECT) Authorization Request Form

Electroconvulsive Therapy (ECT) Authorization Request Form (PDF)

Neuropsychological Testing Authorization Request Form 

• Neuropsychological Testing Authorization Request Form (PDF)