Companion Benefit Alternatives, Inc.
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Facility-Based Treatment
Outpatient Medication Management
Outpatient Mental Health Treatment
Outpatient Substance Use Disorder Treatment
SC Department of Mental Health Treatment
Peer to Peer Request
Claim Support Request
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Choose a Form
Facility-Based Treatment Form
Outpatient Medication Management
Initial Outpatient Mental Health Treatment Request
Outpatient Substance Use Disorder Treatment Request
SC Department Of Mental Health Initial Outpatient Treatment Request
Provider Application Form
Peer to Peer Request Form
Claim Support Request
Discharge Form
MAT Request - Medical Assisted Treatment Form
Continued Outpatient Mental Health Treatment Request
SC Department Of Mental Health Continued Outpatient Treatment Request
Extended Outpatient Mental Health Treatment Request
Outpatient Mental Health Treatment Request
Psychological/Neuropsychological Testing Preauthorization Request Form
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Request for Health Coaching Form
Request for Health Coaching Form
Program Requested:
Health Coaching for Depression
MOMS Support Program
Recovery Support Program
First Name:
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Last Name:
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Date of Birth (mm/dd/yyyy):
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Enter a date in mm/yy/dddd format.
Member ID:
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Telephone Number:
Area Code
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First Three Digits
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Last Four Digits
10 digits (numeric values only) are required. E.g. (803) 555-3434
10 digits (numeric values only) are required. E.g. (803) 555-3434
10 digits (numeric values only) are required. E.g. (803) 555-3434
10 digits (numeric values only) are required. E.g. (803) 555-3434
10 digits (numeric values only) are required. E.g. (803) 555-3434
10 digits (numeric values only) are required. E.g. (803) 555-3434
Alternate Phone Number:
Area Code
(
)
First Three Digits
-
Last Four Digits
10 digits (numeric values only) are required. E.g. (803) 555-3434
10 digits (numeric values only) are required. E.g. (803) 555-3434
10 digits (numeric values only) are required. E.g. (803) 555-3434
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