Companion Benefit Alternatives, Inc.

Outpatient Mental Health Treatment

Use these forms to request certification for outpatient mental health treatment services (e.g. individual or group therapy). Do not use these forms for services related to substance use disorder (SUD), intensive outpatient programs (IOP) or partial hospitalization programs (PHP). Please use the psychological testing form below.

Choose a Form

• Initial Outpatient Mental Health Treatment Request

  Use this form to request certification of initial outpatient mental health services (e.g. individual or group therapy). Do not use this form to request certification of psychological testing. Please use the psychological testing form below.

• Continued Outpatient Mental Health Treatment Request

  Use this form to request certification if the patient needs continued mental health services (e.g. individual or group therapy) after the services we approved in the initial request have been or will be used.

• Extended Outpatient Mental Health Treatment Request

  Use this form to request certification if you have been treating the patient for three or more years and the patient needs additional mental health services (e.g. individual or group therapy).

• Psychological/Neuropsychological Testing Preauthorization Request

  Use this form to request psychological/neuropsychological testing.