Provider forms

Download and print commonly requested forms for prior authorizations, coverage determination requests, referrals, screenings, enrollment for electronic claims submission and remittance advices, and more.

Authorization request forms
- Behavioral Health Treatment Authorization Request (PDF, 99 KB)
- Community Based Adult Services (CBAS) Inquiry (PDF, 242 KB)
- Community Based Adult Services (CBAS) Treatment Authorization Request (PDF, 782 KB)
- DME Treatment Authorization Request (PDF, 171 KB)
- Home Health Treatment Authorization Request (PDF, 187 KB)
- Long-Term Care Custodial Authorization Request - Room & Board (PDF, 257 KB)
- Long Term Care Authorization Request (PDF, 330 KB)
- Outpatient Treatment Request (PDF, 225 KB)
- Prescription Drug Prior Authorization and Step Therapy Exception Request (PDF, 1.4 MB)
- Skilled Nursing Facility service authorization request (PDF, 440 KB)
- Standard drug or drug class prior authorizations request (Medicare) (DOCX, 231 KB)
- Transportation Ambulatory Wheelchair Request (PDF, 190 KB)
- Transportation Gurney Request (PDF, 209 KB)
- Transportation physician certification - non-emergency or non-medical (Medi-Cal and Cal MediConnect) (PDF, 178 KB)
Referral forms
- Behavioral Health Treatment Referral steps and options (PDF, 64 KB)
- Beacon Health Options (Behavioral Health Services) Primary Care Physician Referral (PDF, 274 KB)
- Population Health Management / Case Management Referral (PDF, 57 KB)
- Social Services Referral (PDF, 146 KB)
Other patient care forms
- Age-appropriate physical evaluation templates (PDF, 144 KB)
- Appointment of representative, English (PDF, 71 KB)
- Appointment of representative, Spanish (PDF, 25 KB)
- Critical Incident Report (PDF, 403 KB)
- Electronic Staying Healthy Assessment Format Notification (PDF, 150 KB)
- Initial Health Assessment (IHA) Audit, Medi-Cal (PDF, 158 KB)
- Pregnancy Notification Form-Medi-Cal Patients (PDF, 168 KB)
Claims and payments forms and templates
- 10-Day Notice Fax Cover Sheet (DOCX, 185 KB)
- 274+ Flat File Sample (XLSX, 31 KB)
- Claims Fax Cover Sheet (PDF, 1 MB)
- EDI Inquiry Form (online)
- Medicare and Cal MediConnect Remittance Advice Format (XLSX, 126 KB)
- Medi-Cal Remittance Advice Format (XLSX, 18 KB)
- Provider Data Confirmation (PDC) Form (DOCX, 85 KB)
- SNF Claims Billing Guide (PDF, 293 KB)
- Third Party Liability (TPL) Fax Cover Sheet (DOCX, 185 KB)
Provider dispute forms
- Provider Dispute Resolution Request (PDF, 522 KB)
- Provider dispute resolution request (multipe claims) spreadsheet (PDF, 116 KB)
- Waiver of Liability (DOCX, 93 KB)

Medical care solutions

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Prior authorization list

View the list of medical services and procedures requiring medical necessity review or supplemental documentation prior to payment.

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Provider Connection

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Blue Shield of California Promise Health Plan has neither reviewed nor endorsed this information.

Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association. Blue Shield of California Promise Health Plan is a Medicare Advantage HMO plan with a Federal Government contract in California. Enrollment in Blue Shield of California Promise Health Plan depends on contract renewal.

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