PerformCare PerformCare
  • Report Fraud
  • Home
    • العربية (PDF)
    • 中文粵語 (PDF)
    • Français (PDF)
    • Deutsch (PDF)
    • ગુજરાતી (PDF)
    • Kreyòl Ayisyen (PDF)
    • Italiano (PDF)
    • 한국어 (PDF)
    • 中文普通话 (PDF)
    • ភាសាខ្មែរ (PDF)
    • Pennsylvania Deitch (PDF)
    • Polski (PDF)
    • Português (PDF)
    • Русский (PDF)
    • Español (PDF)
    • Tiếng Việt (PDF)
  • Careers
    • About PerformCare
    • News
    • Members homepage
    • Self-service Tools
    • Find a provider
    • How to get care
    • Your benefits
    • Your health and wellness
    • Suicide prevention awareness
    • Resources and information
    • Member contact information
    • Complaints and grievances
    • Important news for you
    • Providers Homepage
    • Policies
    • Important news for you
    • Claims and billing
    • Self-service Tools
    • Forms
    • Latest updates
    • Training and education
    • Resources and information
    • Quality improvement
    • Member wellness resources
    • Complaints and grievances
  • Community
  • Contact
  • Report Fraud
  • Home
    • العربية (PDF)
    • 中文粵語 (PDF)
    • Français (PDF)
    • Deutsch (PDF)
    • ગુજરાતી (PDF)
    • Kreyòl Ayisyen (PDF)
    • Italiano (PDF)
    • 한국어 (PDF)
    • 中文普通话 (PDF)
    • ភាសាខ្មែរ (PDF)
    • Pennsylvania Deitch (PDF)
    • Polski (PDF)
    • Português (PDF)
    • Русский (PDF)
    • Español (PDF)
    • Tiếng Việt (PDF)
  • Careers
  1. Home
  2. Providers
  3. Resources and Information
  4. Family-Based Mental Health Services (FBMHS) Forms
  • Providers
    • Policies
    • Provider Notices
    • Important news for you
    • Claims and billing
    • Self service tools
    • Forms
    • Latest updates
    • Training and education
    • Resources and information
    • Prior authorization lookup tool
    • Quality improvement
    • Member wellness resources
    • Complaints and grievances

Family-Based Mental Health Services (FBMHS) Forms

  • Additional Units/Authorization Extension Request Form (PDF)
  • FBMHS Checklist (PDF)
  • FBMHS Recommendation Letter (PDF)
  • FBMHS Treatment Review Form (PDF)
  • Initial Request/Referral Form (PDF)
  • Provider Choice Form — Capital Area (PDF)
    • Provider choice Form — Capital Area (Spanish) (PDF)
  • Provider Choice Form — TMCA (PDF)
    • Provider Choice Form — TMCA (Spanish) (PDF)
  • Careers
  • Site Map
  • Report fraud, waste, or abuse
  • Non-discrimination notice (PDF)

 

Connect with us on social media

Hours of Operation: 24 Hours a Day, 7 Days a Week
Our Address: 8040 Carlson Road, Harrisburg, PA 17112

This site contains links to other Internet sites. PerformCare is not responsible for the content of these sites. Please see Terms of Use. View the Site Map.

Copyright © 2009-2025 PERFORMCARE. All rights reserved. Please see Privacy Notice and Notice of Privacy Practices (PDF). Visit AmeriHealth Caritas - The Industry Leader & Expert in Medicaid Managed Care

Get Adobe Acrobat Reader