Forms & Templates

Provider Templates and Forms

• Carelon Behavioral Health Telehealth Provider Attestation
• Facility Roster
• Psychological Testing Referral Form
• W-9 (Editable Version)
• ACH Enrollment Form PCP
• Add, Changes, Deletes PCP

Member Forms

• Designated Client Representative Form
• Designated Client Representative Form – Spanish
• Release of Information
• Release of Information – Spanish
• Member Rights, Responsibilities, EPSDT, and Advance Directives