Forms
Provider Nomination Form
CONTACT works hard to develop a comprehensive network of providers to meet your behavioral health needs. If you have a provider whom you would like us to consider for addition to the network, you can use this form. We will review the request and contact the provider to discuss this option.
Transition of Care Form for Managed Care Members
If you are a new CONTACT Managed Care member and are currently receiving behavioral health treatment from a non-CONTACT provider, please complete this form.
Member Reimbursement Instructions for Managed Care Members
If you paid for out-of-network services and are seeking reimbursement, use this checklist to verify that you are submitting all the needed information to process the claim.
Please Note: Member reimbursements are only available to you:
- If your plan includes out-of-network benefits
- You used an out-of-network provider AND
- You have paid for the services out-of-pocket
Continuity and Coordination of Care form
An important aspect of health care is coordination between all providers involved, including PCPs and behavioral health providers. This form is available to all CONTACT members. Have member complete form, whether consenting to coordination or not, and fax to CONTACT at 602-414-7171.