These revised OTR forms are now in use! Please update immediately because after April 30, 2012, only these revised OTR forms will be accepted.
All Maryland providers: Please continue to use your mandated State of Maryland Uniform Treatment Plan Form to request outpatient authorizations. The new standard OTR does NOT replace any mandated form (e.g. Maryland) or specialized OTR forms (KY CMHC OTR, Autism OTR, PA Substance Abuse OTR).
Standard OTR Form
Pennsylvania Substance Abuse OTR Form
CoventryCares of Kentucky OTR Form [This form is for KY CMHC providers only. KY non-CMHC providers: please use the Standard OTR Form.]
Autism OTR Form
For additional information including an OTR instructional tool, click here.
Any questions? Please call Provider Relations at our new direct, toll-free Provider Relations number: 855.995.4086.