Effective July 1, 2024

Use the forms on this page as needed in your care of IBHP members. You will need to download and install Adobe Acrobat Reader to use the PDF forms.

• Ad Hoc/Out-of-Network Provider Request Form  (Word download)
• Claim Dispute Form  (online form)
• Concurrent Review Form  (Word download)
• Critical Incident Report Form  (online form)
• Discharge Information Form  (Word download)
• Emergency Room Precommitment Services Invoice  (Word download)
• Initial Agreement for Wraparound  (pdf)
• Initial Request for Inpatient Care Form  (Word download)
• Intensive Care Coordination Program Referral Form English  Spanish  (pdf)
• Member Authorization for Use and Disclosure of/Consent to Release Protected Health Information (PHI) -- ALL PARTS OF THE FORM MUST BE COMPLETED. IF ANY PART IS LEFT BLANK IT WILL BE RETURNED TO YOU TO FIX.
  • Online AUD form
  • Updated English form and instructions (pdf)
  • Updated Spanish form and instructions (pdf)
• Outpatient Care Authorization Request Form  (Word download)
• Residential Treatment and Psychiatric Residential Treatment Form  (Word download)
• Retrospective Review Request Form  (pdf)
• Psychological Testing Preauthorization Request Form  (Word download)
• Statewide Wraparound Referral  (pdf)
• Treatment Record Review (TRR) Tool for Idaho  (pdf)

SUPRT Assessment Forms and FAQ

• SUPRT-A: Assessment Form and Report

Adult/Client Forms

• SUPRT-C: Annual Form
• SUPRT-C: Baseline Form
• SUPRT-C: Reassessment Form

Youth/Client (12-17) Forms

• SUPRT-C: Baseline Form
• SUPRT-C: Reassessment Form

Child (5-17)/Caregiver Forms

• SUPRT-C: Baseline Form
• SUPRT-C: Reassessment Form

SUPRT Frequently Asked Questions