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.
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.

Behavioral Health Pre-authorization Forms
Form	Description	Instructions
Outpatient Treatment Plan Request (PDF)	This form is for Federal Employee Program (FEP) members.  A treatment plan is requested, but not required, for members with FEP primary coverage.	Call FEP Customer Service at 1 (877) 668-4654 in order to verify the type of coverage, benefits, eligibility, co-payments, and deductible. Please fax the completed form to 1 (888) 496-1540.
Behavioral Health Treatment Plan Request	This form is for members who require an authorization for behavioral health outpatient treatment, including chemical dependency. Submit this form to Regence for authorization of continued services.	Please call Regence Behavioral Health Customer Service at 1 (800) 780-7881 for any authorization questions.  Complete the Treatment plan request form securely online or you may download the form (PDF) and submit by fax to Regence Behavioral Health 1 (888) 496-1540.