Uniform referral form a primary dentist uses to refer an HMO/dental plan member to a specialist for consultation.
- Completed by
- Primary or requesting dentist
- Issued by
- Maryland Insurance Administration
- Format
- Language
- English
Maryland Uniform Treatment Plan Form, Behavioral Health
Maryland carriers and private review agents must accept one uniform treatment plan when a practitioner seeks authorization for mental health or substance use disorder services. Behavioral health practitioners meet it for outpatient, intensive outpatient, partial hospital, inpatient, residential, ECT, rTMS, ABA, psychological testing, biofeedback and telehealth requests. Reviewers may not demand changes to the form or additional treatment plan forms.
Who completes it
The treating practitioner, such as a psychiatrist, psychologist, LCSW-C, LCPC or BCBA, completes page 1 and the pages for the requested service, and signs to attest a current valid license in the state. The patient completes nothing.
Submitting and payment
- How to submit it
- Submit the completed form to the carrier or its behavioral health manager. Insurance Article 15-10B-06(e) allows it to be submitted by electronic transfer.
Good to know
- Page 1 covers level of care, diagnoses, treatment modalities, medication classes, and severity ratings for symptoms such as suicidal or homicidal ideation, depression, psychosis and substance use.
- ECT or rTMS requests need a clinical rationale with medical suitability and failed treatments; ABA requests ask whether a physician or psychologist validated the autism diagnosis.
- Higher-level-of-care requests add impairing behaviors, prior treatment in 6 months, support system, treatment and discharge plans, and six substance use dimensions rated low to high.
- Carriers must accept it under Insurance Article 15-10B-03(d) and COMAR 31.10.21.02-1H, effective February 24, 2020, and may not require other treatment plan forms.
Get the official form
Download the current version from the source each time; forms change without notice.
Uniform Treatment Plan Form (For Purposes of Treatment Authorization)
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Frequently asked questions
Do Maryland insurers have to accept the Uniform Treatment Plan Form?
Yes. Under Insurance Article 15-10B-06(e), a private review agent that requires a treatment plan for mental health or substance use services must accept the uniform form as properly submitted and may not require changes to it or additional treatment plan forms. It must be properly completed and may be sent electronically.
Which services does the Maryland Uniform Treatment Plan cover?
It covers authorization for outpatient care, intensive outpatient, partial hospitalization, acute inpatient, inpatient rehab and detox, residential care, ECT, rTMS, applied behavior analysis, psychological testing, biofeedback and telehealth, with service-specific sections on pages 2 to 4.
What does the Maryland form ask for psychological testing?
It asks for the symptoms or impairment driving the need, the purpose (such as differential diagnosis or treatment planning), substance use in the last 30 days, prior testing of the same type within 12 months, the tests and hours requested, and reasons testing may take longer than standard.