Provider Resources – Forms
- Provider Network Registration Form – for login access to the BHSI Provider Network.
Significant Incident Report
Providers must report all reportable Significant Incidents following a centralized two-step process:
- Report the incident by telephone to the assigned BHSI Service Manager or Service Manager’s supervisor within 24 hours of the incident or upon notification of the incident’s occurrence.
- NEW! A copy of all reportable incidents must be emailed to BHSI.email@example.com or uploaded to the BHSI Quality Provider Portal. You must have an active user name and password to access.Please do not include Protected Health Information (PHI) in the subject line of the submitted documents.
Approvals and Authorizations
- Authorizations Request Instructions effective 2/13/2019 – This document provides instructions for submitting requests for approvals, authorizations and other documents. BHSI no longer accepts faxes as of 3/1/2016.
- BHSI Claims Appeal Form
- MA Exception Process
- BHSI Concurrent Review Form – To provide information needed for a detoxification authorization
- BHSI Authorization to Release Information Form – This is the only version of the form that will be accepted by BHSI.
- Authorization to Release Provider Notice.
- BHSI Outpatient Short Form -To request approval for .5, 1A and 1B Levels of Care.
PA Department of Drug and Alcohol Programs
- DDAP-EFM-1000 Screening Tool Part 1 Client Profile
- DDAP-EFM-1001 Screening Tool Part 2 Client Screen
- DDAP-EFM-1002 ASAM Summary Sheet
- DDAP-EFM-1004 Authorization
- DDAP-EFM-1005 Client Admission
- DDAP-EFM-1005a Client Admission Licensed Program Codes
- DDAP-EFM-1005b Client Admission Detailed Drug Codes
- DDAP-EFM-1006 Services Rendered
- DDAP-EFM-1007 Client Discharge
- DDAP-EFM-1008 Case Management Service Plan
- DDAP-EFM-1009 Grievance and Appeal Reporting
- DDAP-EFM-3000 Clinical Supervision Training Registration Form
- DDAP Terms And Conditions Appendices A-E (PA-6)
Department of Drug and Alcohol Programs specified clauses included in all provider agreements.
- Department of Drug and Alcohol Programs Training Site (DDAP TMS)
Learn about and sign up for DDAP trainings.
- Department Of Drug And Alcohol Programs Responsibilities of the Provider (PA-4)
- BHSI Authorization to Release Information Form (Consent)
BHSI Service Management
801 Market St., Seventh Floor
Philadelphia, PA 19107
PMHCC Case Management
1601 Market St., Seventh Floor
Philadelphia, PA 19109
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