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Get the free PRO NY FIDA Behavioral Health Covered Routine Outpatient Services Form - ENG

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Behavioral Health Service Request Form Covered Routine Outpatient Services Please submit to the Welfare Advocate Complete FIDA (Medicare Medicaid Plan) dedicated fax line: 18555508977 Standard Request
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Pro NY FIDA Behavioral is a form used to report behavioral health services provided to individuals enrolled in the Fully Integrated Dual Advantage (FIDA) program in New York.
Providers of behavioral health services to individuals enrolled in the FIDA program in New York are required to file Pro NY FIDA Behavioral.
Pro NY FIDA Behavioral form can be filled out electronically or manually, with all required information regarding the behavioral health services provided.
The purpose of Pro NY FIDA Behavioral is to track and report behavioral health services provided to FIDA program enrollees for billing and monitoring purposes.
Information such as date of service, type of service provided, duration, and any relevant diagnoses must be reported on Pro NY FIDA Behavioral.
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