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)
- Cal MediConnect CPO Request & Determination Form, Los Angeles County (PDF, 675 KB)
- Cal MediConnect CPO Request & Determination Form, San Diego County (PDF, 532 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)
- Direct Referral Form for Physicians (PDF, 128 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)
- 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 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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