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Authorization request forms
- Behavioral Health Treatment Authorization Request Packet (PDF, 358 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, 326 KB)
- Long Term Care Authorization Request (PDF, 2.9 MB)
- Outpatient Treatment Authorization Request (PDF, 99 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 Physician Certification Statement for Non-Emergency Medical Transportation (Medi-Cal and Cal MediConnect) (PDF, 87 KB)
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Referral forms
- Beacon Health Options (Behavioral Health Services) Primary Care Physician Referral (PDF, 107 KB)
- Community Supports Referral (PDF, 523 KB)
- Population Health Management / Case Management Referral (PDF, 57 KB)
- Social Services Referral (PDF, 146 KB)
- Maternity Care Referral (PDF, 83 KB)
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Other patient care forms
- Age-appropriate Physical Evaluation Templates (PDF, 144 KB)
- Appointment of Representative, English (PDF, 150 KB)
- Appointment of Representative, Spanish (PDF, 335 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)
- Lead Declination Form, English (PDF, 136 KB)
- Lead Declination Form, Spanish (PDF, 122 KB)
- Palliative Care Patient Eligibility Screening Tool (PDF, 449 KB)
- Palliative Care Recertification Tool (PDF, 235 KB)
- Pregnancy Notification Form-Medi-Cal Patients (PDF, 168 KB)
- Provider Request Form for Medi-Cal Continuity of Care (PDF, 534 KB)
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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)
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Provider dispute forms
- Provider Dispute Resolution Request (PDF, 522 KB)
- Provider Dispute Resolution Request (multiple claims) spreadsheet (PDF, 116 KB)
- Waiver of Liability (DOCX, 93 KB)
