Forms

Provider Resources Forms

DDAP Forms


Manuals and Service Agreements


BHSI Provider Network

The BHSI Provider Network allows you to submit claim files, retrieve adjudication files and obtain approval codes for services.

BHSI has made significant changes in operating procedures. Click here to see a copy of the letter sent to providers the week of 2/22/2016. A copy of the instructions of using the new forms can be found here.

Provider Resources - Forms

User Agreement

Provider Network Registration Form - for login access to the BHSI Provider Network.

Significant Incident Report

Providers must report all reportable Significant Incidents following a centralized two-step process:

  1. Report the incident by telephone to the assigned BHSI Service Manager or Service Manager's supervisor within 24 hours of the incident or upon notification of the incident's occurence.
  2. NEW! A copy of all reportable incidents must be emailed to BHSI.quality@phila.gov of uploaded to the BHSI Quality Provider Portal. You must have an active user name and password to access.

    Please do not include Protected Health Information (PHI) in the subject line of the submitted documents.

Philadelphia Department of Behavioral Health Significant Incident Report Form

Approvals and Authorizations

Authorizations Request Instructions effective 2/13/2019 - This document provides instructions for submitting requests for approvals, authorizations and other documents.  BHSI will no longer accept faxes after 3/1/2016.  Update 3/8/2016   Powerpoint from Trainings

BHSI Claims Appeal Form

MA Exception Process

BHSI Concurrent Review Form - This form is used to provide the information needed for a detoxification authorization

NEW! BHSI Authorization to Release Information Form - This is the only version of the form that will be accepted by BHSI.

NEW! Authorization to Release Provider Notice.

BHSI Outpatient Short Form - use this form to request approval for .5, 1A and 1B Levels of Care.