Behavioral Health Forms

Form	Description	Instructions
Alcohol Use Disorders Identification Test (AUDIT) (PDF)	The Alcohol Use Disorders Identification Test (AUDIT) was produced by the National Institute on Alcohol Abuse and Alcoholism, a component of the National Institutes of Health, and is endorsed by the World Health Organization (WHO) as a screening tool to identify heavy alcohol use.
Authorization to Disclose Protected Health Information (PDF)	Patient authorization for health care provider to disclose health information pertaining to mental health treatment, claims, and other medical information, to Regence.	Complete to allow disclosure of protected health information to Regence.
Behavioral Health Referral Request Regence BlueShield - Do not use for Boeing or Federal Employee Plan members.	Use this form for Selections members ONLY for all outpatient mental services and all levels of chemical dependency.	Do not use this form for a Boeing employee or Federal Employee Plan (FEP) member. Complete this form within the first 3 days of seeing member for the initial visit. Indicate procedures. Fax to Regence BlueShield – the number is on the form.
Behavioral Health Referral Request For Regence BlueShield Employees	Use this form for Regence BlueShield employees who have the Selections plan for all outpatient mental services and all levels of chemical dependency.	Do not use this form for a Boeing employee. Complete this form within the first 3 days of seeing member for the initial visit. Indicate procedures. Fax to Regence BlueShield – the number is on the form.
Regence Behavioral Health Outpatient Treatment Plan Request (PDF)	This form is for members with Regence BlueShield coverage who require an authorization for behavioral health outpatient treatment. Please call Regence Behavioral Health Customer Service at 1 (800) 780-7881 for any authorization questions.
Federal Employee Program (FEP) - Treatment Authorization Request	Effective 1/1/2009 the Standard Option pre-authorization requirements will be the same as the Basic Option pre-authorization requirements. All outpatient mental health services for FEP members must be pre-authorized before treatment begins.	Only use this form for Regence BlueShield member if FEP is their primary coverage. This form is not for any other Regence BlueShield plans. A separate treatment plan must be submitted for each provider a member is seeking services from. Not required for psychological testing or if sole treatment is medication management (90682). Verify the type of coverage benefits, eligibility, co-payments, and deductibles the member has by calling 1 (877) 668-4651 Treatment plans expire at the end of the calendar year.
Zung Self-Rating Depression Scale (PDF)	The Zung Self-Rating Depression Scale is a screening tool to identify symptoms of depression in adults. The ZDS is also useful as an outcome measurement tool to track a client's progress over time. The first page contains the screening questions; the second page contains the scoring key.