Support Ticket Request Form
Select Type of Support
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Select type of support that you need.
Human Resources
Related Issue
Billing Related
Issue
Operations Related
Issue
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Payroll Issue
Payroll Discrepancy Form
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Code and pay
a treatment plan
Other Billing
Related Issue
Survey Type
*
Employee Feedback Survey
Employee Exit Survey
Choose Department
*
Select the department related to your issue.
Outpatient Mental
Health Center (OMHC)
Psychiatric Rehabilitation
Program (PRP)
Behavioral Health
Home (BHH)
Substance
Use Disorder Outpatient Program (SUD OP)
Substance
Use Disorder Inpatient Program (SUD IP)
Supportive
Housing Programs & Facilities Management (SHPFM)
Administrative Department
Choose Relevant Option
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Select the option that best describes your issue.
Need
authorization
Need billing
correction
Discharge a
client
Intake a
client
Provider to Revenue Department Billing Request
Verification of other insurance
Provider to Revenue Department
Revenue Department to Provider Clinical Documentation Request
Transfer
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client appointment
Critical Incident
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Peer Medical
Record Review
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Review Assessment
Client Survey Form
Equipment Transfer Request
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Software Access & Subscription Request
Client Grievance
Form
Daily productivity Report
Medical Records Request
Client's First Name
*
Please provide the client's first name for our records.
Client's Last Name
*
Please provide the client's last name for our records.
Client's Date of Birth
*
Provide the client's date of birth for identification purposes.
Client Record ID (Optional)
Provide the unique ID associated with the client's record.
Service Date
*
Provide the date when the service was availed.
Service Code (Optional)
Provide the code related to the service availed, if available.
Select Service Code
90791 Psychiatric diagnostic evaluation OMHC">90791 Psychiatric diagnostic evaluation OMHC
90792 Psychiatric diagnostic evaluation with medical services OMHC
90832 Individual psychotherapy (30 min)-Outpatient OMHC
90833 30 min Psychotherapy add on OMHC
90834 Individual psychotherapy (45 min)-Outpatient OMHC
90836 45 min Psychotherapy add on OMHC
90839 Psychotherapy for crisis, first 60 min OMHC
90840 Psychotherapy for crisis--additional 30 min OMHC
90846 Family psychotherapy without patient present OMHC
90847 Family psychotherapy with patient present (45-60 min) OMHC
90849 Multiple family group psychotherapy 45 - 60 minutes OMHC
H2027 Family psycho-education with consumer present OMHC
H1011 Family psycho-education without consumer present OMHC
90853 Group psychotherapy (not multi-family.) 45-60 minutes OMHC
99202 Evaluation and Management, including Rx -Straight forward, new patient OMHC
99203 Evaluation and Management, including Rx -Low complexity, new patient OMHC
99204 Evaluation and Management, including Rx -Moderately complex, new patient OMHC
99205 Evaluation and Management, including Rx -Highly complex, new patient OMHC
99211 Evaluation and Management, including Rx -Minimal OMHC
99212 Evaluation and Management, including Rx -Straight forward OMHC
99213 Evaluation and Management, including Rx -Low complexity OMHC
99214 Evaluation and Management, including Rx -Moderately complex OMHC
99215 Evaluation and Management, including Rx -Highly complex OMHC
90889 Outpatient Discharge (CMS 1500) OMHC
96130 Psychological Testing Evaluation services by a Physician or other qualified professional. Treatment planning and Report and Interactive feed back to the patient, family members and caregiver's (first hour) OMHC
96131 Psychological Testing, Evaluation and Feedback by Physician or other qualified professional (each additional hour) OMHC
96136 Psychological Test administration and scoring by a Physician or other qualified professional (first 30 minutes) OMHC
96137 Test administration and scoring by a Physician or other qualified professionals (each additional 30 minutes) OMHC
96138 Psychological test administration and scoring by a Technician (first 30 minutes) OMHC
96139 Psychological test administration and scoring by a Technician (each additional 30 minutes) OMHC
36415 Collection of blood by venipuncture OMHC">36415 Collection of blood by venipuncture OMHC
96372 Therapeutic injection OMHC">96372 Therapeutic injection OMHC
S9480 Intensive OP psych svcs, per diem (clinic model) OMHC
H0032 Interdisciplinary team tx planning w/patient present OMHC
H0046 Therapeutic Nursery OMHC
W1760 Intake assessment/enrollment BHH
W1761 Monthly service BHH
H2018-U3 Monthly blended PRP service billing line (adults) PRP
H2018-U2 Monthly blended PRP service billing line (minors) PRP
H2016-52 minimum 60 minute individual/group onsite PRP service PRP
H2016-15 minimum 15 minute individual/group offsite PRP service PRP
H0002 Rehab assessment PRP
H0001 Alcohol and/or Drug Assessment SUD OP/IOP/PHP/RES
H0004 Individual Outpatient Therapy SUD OP
H0005 Group Outpatient Therapy SUD OP
H0015 Intensive Outpatient (IOP) SUD IOP
H2036 Partial Hospitalization SUD PHP
H2036 22 Partial hospitalization (6+ hrs/day of services) SUD PHP
H0014 ADAA Certified Ambulatory Detox Program SUD WM
H0038 Individual Peer Recovery Support Services SUD OP
H0024 Group Peer Recovery Support Services SUD OP
99202 HG MAT Initial Intake (Evaluation and Management, Including Rx-Straight forward, new patient) SUD OP
99203 HG MAT Initial Intake (Evaluation and Management, Including Rx-Low complexity, new patient) SUD OP
99204 HG MAT Initial Intake (Evaluation and Management, Including Rx Moderately complex, new patient) SUD OP
99205 HG MAT Initial Intake (Evaluation and Management, Including Rx-Highly complex, new patient) SUD OP
99211 HG MAT Ongoing (Evaluation and Management, including Rx -Minimal) SUD OP
99212 HG MAT Ongoing (Evaluation and Management, including Rx -Straight forward) SUD OP
99213 HG MAT Ongoing (Evaluation and Management, including Rx -Low complexity) SUD OP
99214 HG MAT Ongoing (Evaluation and Management, including Rx -Moderately complex) SUD OP
99215 HG MAT Ongoing (Evaluation and Management, including Rx -Highly complex) SUD OP
W7310 ASAM Level 3.1 SUD RES
W7330 ASAM Level 3.3 SUD RES
W7350 ASAM Level 3.5 SUD RES
RESRB Room and Board SUD RES
Service Type
Provide the Service type related to the service availed, if available.
Select Service Type
Outpatient mental health center (omhc)
Substance use disorder (sud)
Psychiatric rehabilitation program (prp)
Your Name
*
Please provide your full name.
Your Email Address
*
Please provide your email address.
Requested Inclusive Dates From
*
Provide the initial date of the records you are requesting.
Requested Inclusive Dates To
*
Provide the final date of the records you are requesting.
Type
*
Entrance
Exit
Satisfaction
Choose Priority Level
*
Select the urgency level of your issue.
Discharge Date (Optional)
Provide the date when the discharge was availed.
Discharge Address (Optional)
Provide the discharge address.
Select Discharge Address
248 North Fulton Avenue, Baltimore, MD
809 North Rose Street, Baltimore, MD
819 North Fremont Avenue, Baltimore, MD
1006 East North Avenue, Baltimore, MD
1114 East 20th Street , Baltimore, MD
1620 Druid Hill Avenue, Baltimore, MD
1638 Ruxton Avenue , Baltimore, MD
1649 Darley Avenue , Baltimore, MD
1723 Gwynns Falls Parkway, Baltimore, MD
2140 Druid Hill Avenue, Baltimore, MD
3021 Garrison Boulevard, Baltimore, MD
3310 Eastern Avenue , Baltimore, MD
3415 Holmes Avenue , Baltimore, MD
1116 East 20th Street, Baltimore, MD
Originating Address
*
Provide the originating address.
Select Originating Address
248 North Fulton Avenue, Baltimore, MD
809 North Rose Street, Baltimore, MD
819 North Fremont Avenue, Baltimore, MD
1006 East North Avenue, Baltimore, MD
1114 East 20th Street , Baltimore, MD
1620 Druid Hill Avenue, Baltimore, MD
1638 Ruxton Avenue , Baltimore, MD
1649 Darley Avenue , Baltimore, MD
1723 Gwynns Falls Parkway, Baltimore, MD
2140 Druid Hill Avenue, Baltimore, MD
3021 Garrison Boulevard, Baltimore, MD
3310 Eastern Avenue , Baltimore, MD
3415 Holmes Avenue , Baltimore, MD
1116 East 20th Street, Baltimore, MD
Originating Apartment (Optional)
Provide the originating apartment.
Originating Room (Optional)
Provide the originating room.
Originating Bed (Optional)
Provide the originating bed.
Destination Address (Optional)
Provide the destination address.
Select Destination Address
248 North Fulton Avenue, Baltimore, MD
809 North Rose Street, Baltimore, MD
819 North Fremont Avenue, Baltimore, MD
1006 East North Avenue, Baltimore, MD
1114 East 20th Street , Baltimore, MD
1620 Druid Hill Avenue, Baltimore, MD
1638 Ruxton Avenue , Baltimore, MD
1649 Darley Avenue , Baltimore, MD
1723 Gwynns Falls Parkway, Baltimore, MD
2140 Druid Hill Avenue, Baltimore, MD
3021 Garrison Boulevard, Baltimore, MD
3310 Eastern Avenue , Baltimore, MD
3415 Holmes Avenue , Baltimore, MD
1116 East 20th Street, Baltimore, MD
Destination Apartment (Optional)
Provide the destination apartment.
Destination Room (Optional)
Provide the destination room.
Destination Bed (Optional)
Provide the destination bed.
Agents
Provide the Agent
Select Agent
CARTAGENA Jr, ALBERTO M.
Cruz, Kevin Louis
Arbon, James
Madrid, Karla
Phone
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