Providers > Forms

Application forms

Provider candidate applications should include the following attachments.

Candidates should also submit:

  • DEA certificate – for providers licensed to write prescriptions
  • Licensures and Certifications
  • Malpractice insurance face sheet
  • Copy of highest academic credential (diploma or transcript)

Upon receiving completed material the credentialing team will begin the verification process. Once vetted, your credentialing material will be submitted to the Credentialing Committee for consideration. If approved, you will be notified in writing, after which you will begin to receive referrals.

Re-credentialing occurs every three years, and throughout the three-year period you will be asked to update information as required. Prior to expiration of your credentialing cycle, you will receive a re-credentialing application packet.

If you represent a group facility and are interested in Delegated Credentialing please contact the Office of Provider Relations at (215) 746-7906.

For additional information about referrals and the claims process, please refer to the PENN Behavioral Health provider guidelines.

PENN Behavioral Health Provider Claims forms

Details on the use of these forms are found in the claims information section.

Clinical Information and Forms

Mental Health and Chemical Dependency Benefit Clinical Information and Forms

Note: for Out-of-Network claims, please contact our Office of Network Development and Provider Relations at (215) 746-7906 or email.

 

Provider Application (PDF)

 

Credentialing Checklist (PDF)

 

Peer Reference (PDF)

 

Criminal Clearance Report (PDF)

 

Child Abuse Clearance (PDF)

 

Signed W-9 (PDF)

 

CMS (formerly HICFA) (PDF)

 

CMS Form Instructions (PDF)

 

Conversion Of Benefits (PDF)

 

Statement of Understanding (PDF)

 

EAP Intake Form (PDF)

 

EAP Case Closing Summary (PDF)

 

Authorization to Release Limited Information (Based on Formal Referral) (PDF)

 

Outpatient Concurrent Review Form (PDF)

 

Authorization to Release Information (to Primary Care Physician) (PDF)

 

Primary Care Physican Report (PDF)

 

Member Rights and Responsibilities (PDF)

 

Conversion Of Benefits (PDF)