HIRSP - For Providers

Providers are required to provide HIRSP with various types of information. This section of the HIRSP website provides important forms to assist with this requirement. Forms are in PDF format for ease of printing.

Recent Notifications/Updates
HIRSP Provider Rates (Note: you will need to use a program that will read Microsoft Excel documents to view these documents). 2011 HIRSP Provider Rates (16 MB) 2010 HIRSP Provider Rates (13 MB) 2009 HIRSP Provider Rates (12 MB) 2008 HIRSP Provider Rates (13 MB) Understanding Your Provider Remittance Advice (PRA)
WPS Medical Policies (at the WPS website)

Privacy Forms
HIPAA Privacy Authorization for Use or Disclosure Form

Pharmacy Information
MedTrak Pharmacy Services For formulary and pharmacy benefit information please visit the HIRSP Pharmacy Benefit Administrator's site: >> MedTrak Pharmacy Services

Outpatient Behavioral Health Treatment Forms
Certification Request/ Psychological and Neuropsychological Testing Certification Request/Initial Outpatient Treatment Certification Request/Follow-Up Outpatient Treatment Request Certification as an Autism Qualified Provider (Professional Staff Update Notification form) Determine the service level for your patient (Intensive vs. Non-intensive) (Autism Spectrum Progress Report form).