Provider Forms
Psychiatric Rehabilitation Programs (PRP)
- PRP - Adult Request Initial
- PRP - Adult Request Concurrent
- PRP - Minors Request Initial
- PRP - Minors Request Concurrent
- PRP – Authorization Staggering
- PRP – TAY Concurrent Request
- PRP – TAY Initial Request
Residential Rehabilitation Programs (RRP)
Release of Information (ROI)
- DORS ROI and Request for Services (pdf)
- ROI for Sharing Data with MCOs (pdf)
- Release of Information/Authorization for Disclosure (English) (pdf)
Maryland RecoveryNet (MDRN)
Division of Rehabilitation Services (DORS)
Third Party Liability: Submission of Claims for Medical Support Beneficiaries After 100 Days
ECT
ECT Outpatient Concurrent Request
ECT Outpatient Initial Request
Mental Health
Higher Level of Care Concurrent Request
Higher Level of Care Initial Request
Mobile Treatment
Mobile Treatment - Adult Concurrent
Mobile Treatment - Adult Initial
Mobile Treatment Child and Adolescent Concurrent Request
Mobile Treatment Child and Adolescent Initial Request
Psychological Testing
Psychological Testing Request - Adult
Psychological Testing Request - Child
Specialized Rehabilitation Program
Specialized Rehabilitation Program – Concurrent Request
Specialized Rehabilitation Program – Initial Request
Substance Use Disorder
Withdrawal Management Substance Use Disorder-Higher Level of Care Concurrent Form
Withdrawal Management Substance Use Disorder-Higher Level of Care Initial Form
Substance Use Disorder Ambulatory Detox – PHP-IOP Concurrent Request
Substance Use Disorder Ambulatory Detox – PHP Initial Request
Substance Use Disorder - Higher Level of Care Concurrent Request
Substance Use Disorder - Higher Level of Care Initial Request
Substance Use Disorder - IOP Request
Target Case Management
Target Case Management – Child and Adolescent – Level I & II
Target Case Management Level III Request
TBS
Transcranial Magnetic Stimulation
Transcranial Magnetic Stimulation - Concurrent Request
Transcranial Magnetic Stimulation - Initial Request
Clinical Discharge
Inpatient Administrative Day Request
Inpatient Administrative Day Request
Respite Service Request