• Basis-24 EULA
• Cover Letter EULA (PDF)
• Documentation for Uninsured Eligibility Benefit (PDF)
• Intermediary Authorization Form (PDF)
• Maryland Additional User Account Request Form (PDF)
• Maryland Additional User Account Request Form for Multiple Users (PDF)
• Provider Account Request Form (Coming Soon)
• ProviderConnect Multiple Matching Records Resolutions Form
• TBS Referral Form (Coming Soon)
  

• Outpatient Concurrent Review Form (PDF)
• TBS Referral Form

Outcome Measurement System (OMS)

State and federal governments are requiring Public Mental Health Systems to collect outcome data regarding each consumer who receives services. In Maryland, specific information regarding the treatment outcomes for individuals from 6 to 64 years old will be collected from Outpatient Mental Health Centers (OMHCs), Federally Qualified Health Clinics (FQHCs), and Hospital-based clinics.

Consumer outcomes regarding the management of their illnesses and the quality of their lives are the most important measures of the benefit provided by services in the Public Mental Health System. In addition, information about outcomes of mental health services is a key element to supporting the recovery and resiliency of consumers (along with access to appropriate services, active consumer participation in treatment decisions, and a recovery culture) because knowledge about what treatments are effective is empowering and engenders hope.

COMAR 10.09.70.07 permits the Mental Hygiene Administration to establish the process for pre-authorization of services.

• OMS Interview Guide (PDF)

• Discharge Information Sheet (PDF)

• Adult Questionnaire (PDF)

• Definitions for Adult OMS Interview (PDF)

• Adult Questionnaire Response Cards (PDF)

• Adult Discharge Form – Consumer Not Participating (PDF)

• Child and Adolescent Questionnaire (PDF)

• Child and Adolescent Response Cards (PDF)

• Child and Adolescent Discharge Form – Consumer not Participating (PDF)

If you need additional forms that are not listed on this page, click here.