The Holman Group - Provider Manual

Explanation of Forms:

The following section provides an explanation for each Holman form.

Authorization for Release of Information Form
This form is found on the reverse side of the EAP/MAP and Holman's Insurance Billing forms. This form must be completed and signed by the client during his/her first session. If the client is a Formal Management Referral (see Section “Formal Management Referrals”), he/she must complete and sign the bottom of the form as well.

Clinical Assessment Form
This form must be completed in full for all Holman clients. Send or fax at (818) 704-4252 the signed and dated copy to The Holman Group immediately following the first date seen. Keep the original for your records.

PLEASE NOTE: Payment will not be made for any session for which a Clinical Assessment form is not on file with The Holman Group.

Client Information Form
This form must be completed in full for all Holman clients. Send or fax at (818) 704-4252 the signed and dated copy to The Holman Group immediately following the first date seen. Keep the original for your records

Coordination of Care Form
This form is used to coordinate care with other Health Care Practitioners. This form gives the provider consent to release confidential Information to any other provider treating the patient.

Request for Treatment Authorization (Renewal) Form.
If you feel that the client needs additional treatment session(s) beyond the initial treatment sessions authorized, you must complete this form and submit it to our Utilization Review Department for review by Care Management.

EAP Billing Form
This form is used to bill all authorized EAP/MAP sessions.

Language Capability Attestation (Disclosure) Form
This form is used for providers to report language capabilities by self or office staff.

Insurance Billing Form
This form is used to bill all sessions beyond the client's free EAP/MAP sessions. This form will come to you along with the initial “Request for Treatment Authorization” form.

Progress Notes Form
This form should contain significant data regarding progress toward stated treatment goals, significant observations about appearance and/or behaviors, documented attendance at support groups and any changes in the treatment plan. Notes must be dated and signed. A note should be made for each session. These records must be maintained in the client's file.

Discharge Summary Form
This form is used for termination of treatment. This form should be completed at the termination of treatment. If two or more months have elapsed since the client was seen for a session, the case should be considered closed unless part of an approved treatment plan. Please retain the original form in your chart and forward a copy to The Holman Group, Attention: Utilization Review Department.

Grievance Form
This form is for the client to use to file a formal grievance. This form is in your Holman HMO, EPO and PLHSO contracts. Additional forms are available by contacting our Provider Relations Department.

Client Contact Record form.
Clinical records MUST be maintained for seven (7) years. All laws, regulations and ethics governing confidentiality and release of information apply. Any provider who violates confidentiality laws, regulations or professional ethics will be subject to immediate contractual termination.