3545 N.W. 58th St., Ste. 600, Oklahoma City, OK 73112
Phone: 405-717-8879 or 800-543-6044, ext. 8879
Fax: 1-405-949-5459 or 1-405-949-5501

MENTAL HEALTH REQUEST

This form must be completed and accompany all requests. Incomplete forms will not be reviewed.


 
 
 
 
 
 
 
 
 
 
 
 
 

 

 
 

 

 

 

 
 



 
 




 





 
 




 
 RevCode 0905         RevCode 0906         S9480
 
 

 

NOTE: Certification is valid only for covered billing codes. If non-covered codes/items are billed, they will not be covered by the plan, and will be the member's financial responsibility

 

 
 

** All information is required for review. Information provided is private and confidential. **

NOTE: These benefits are applicable only if the patient is an eligible enrolled member of a HealthChoice plan. All benefits are subject to the deductible, coinsurance and policy provisions. Please verify benefits and eligibility by calling the medical claims administrator toll-free at 800-323-4314.

MEDICARE PATIENTS: If HealthChoice provides coverage that is supplemental to Medicare, all requested services must be approved by Medicare. The Medicare EOB should be filed for claims processing.