Forms

Behavioral Health Direct

• Provider Medicaid-Focused Attestation Form (XLS)

Behavioral Health Referrals for Children, ages 1-5

The first five years of life are critical for social-emotional development. As an early childhood provider, you are in a key position to notice concerns and support families. Behavioral health services can strengthen family relationships, help children express emotions, and prevent long-term challenges.

As the year is nearing closure, YCCO is hoping to any young member in this age group receives a timely and appropriate referral for Behavioral Health services that will address the parents’ concerns as well as their primary care and/or early childhood provider.

Below is a list of providers that accept and serve children and their parents/caregivers:

• Yamhill CCO Behavioral Health Providers Who Serve Members Ages 0-5 (PDF)

Care Coordination, Care Management & Community Health Hub

As a provider, you can support your patient by requesting a Care Coordinator, Care Manager or a Community Outreach Specialist. Our Community Health Hub is equipped to address the needs of your patients and connect them with valuable resources.

Referrals can be made by anyone in your office, local community partners, or through healthcare professionals involved in the patient’s care.

To request a Community Health Worker for your patient or their eligible family members, simply contact Customer Service at 1-855-722-8205 or fill out the form.

• Care Management and Community Health Hub Request (PDF)

Once the referral is made, your patient will receive personalized, one-on-one support tailored to their specific needs.

Home Changes for Health Support (Formerly Climate Devices)

• Home Changes for Health Support (Formerly Climate Devices) Request Form (PDF)
• Spanish Climate Device Request Form (PDF)

Health Related Social Needs (HRSN) Provider Onboarding Resources

• HRSN Provider Training Module: Enrolling as an HRSN Service Provider

• OAR 410-120-2005

• Oregon CCO Billing Guide (HRSN)

• Ayin HRSN Billing Guide

• Ayin HRSN Online Invoice Submission Guide

• MMIS Provider Enrollment Guide
• HRSN Fee Schedule

FamilyCore Program

FamilyCore is a community services network connecting parents with a broad support system to meet challenges head-on and to nurture strong families with children ages 0–5.

FamilyCore can receive referrals from providers or patients. Use the form to submit a Yamhill FamilyCore referral.

• Submit a Yamhill FamilyCore referral
• Visit Yamhill FamilyCore

Flexible Services (Formerly Health Related Services)

YCCO members may need special health related services to improve the overall quality of life which are not covered under the prioritized guidelines. If a YCCO member needs special services, providers can submit a Flexible Services Request Form.

• Flexible Services Request Form (PDF)

Housing

• Housing Fillable Request Form (PDF)
• Spanish Housing Fillable Request Form (PDF)
• HRSN Housing Service Plan Form (PDF)
• Spanish HRSN Housing Service Plan Form (PDF)
• YCCO HRSN Home Modification & Remediation Scope of Work Form (PDF)
• Spanish HRSN Home Modification & Remediation Scope of Work Form (PDF)
• Verification of Landlord/Tenant Relationship and Rent Owed (if no written lease) (PDF)
• Spanish Verification of Landlord/Tenant Relationship and Rent Owed (if no written lease) (PDF)

Information Sharing

• YCCO Information Sharing Authorization Form (PDF)
• Spanish YCCO Information Sharing Authorization Form (PDF)

Nutrition

• YCCO Nutrition Request Form (PDF)
• Spanish Nutrition Request Form (PDF)

Prior Authorization: Behavioral Health

• YCCO ABA PA Form (PDF)
• YCCO BH HLOC PA Fax Form (PDF)
• YCCO BH Outpatient PA Form (PDF)
• YCCO TMS PA Form (PDF)

Prior Authorization: Pharmacy

Prior Authorization requests for medications and medically grade formula.

• Pharmacy PA Form (PDF)

Prior Authorization: Physical Health

• YCCO Physical Health (Medical) PA Request Form (PDF)
• YCCO Transplant PA Request Form (PDF)
• YCCO TOC PA Form (PDF)

Social Determinants of Health

The SDOH Metric requires all YCCO contracted providers to train staff who conduct SDoH screening with members. 

SDOH Training addresses the following:

• Trauma Informed Care,
• Motivational Interviewing,
• Empathic Inquiry, and
• Empathic Inquiry, Social Needs Screening Data & Clinical Workflows.

Complete the Social Determinants of Health (SDOH) Screening and Referral Metric Form ******

As YCCO contracted providers, you are responsible for ensuring that your staff, who conduct SDOH screenings, complete training in each category mentioned above. Once the training is completed, please submit the SDOH Training Attestation Form to providerrelations@yamhillcco.org as proof of completion.

The link below provides SDOH Screening Training Modules and Social Needs Training Resources Developed by the Oregon Rural Practice-based Research Network (ORPRN) and the Oregon Health Authority Transformation Center to support and meet the SDOH Screening and Referral Incentive Metric implementation.

• SDOH Screening & Referral Metric Social Needs Training Resource (PDF)
• SDOH Training Attestation Form (PDF)

Submitting an Appeal on Behalf of a Member

• OHP 3302 Appeal and Hearing Request (PDF)

Wraparound services

Wraparound services help youth, and their families accomplish healthy lifestyle goals. Services include a care coordination planning process with a series of steps to help young people grow up in their homes and identify challenges faced.

Learn more about Wraparound services

Downloadable PDFs:

Submit for to request wraparound services for a member.

• Wrap Referral Form (PDF)

Submit form to report any barriers families may be experiencing in receiving wraparound services. Reports are reviewed and discussed to identify solutions to barriers.

• Barrier Submission Form (PDF)

Learn more about the Barrier Resolution Process Diagram.