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

 
Claims and payments forms and templates

 
Delegation oversight forms

 
Provider dispute forms

 
Referral forms

 
Other patient care forms

 

Medical care solutions

Review medical care solutions for Blue Shield Promise plans.

View and search the list of all clinical policies and procedures

Prior authorization list

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

View prior authorization list

Provider Connection

Access network provider tools on Provider Connection website.

Health Care Options: (844) 580-7272  {TTY: {800) 430-7077}, Monday through Friday from 8 a.m. — 6 p.m. 

For information on Blue Shield Promise Cal MediConnect Plan and other Cal MediConnect options for your health care, call the Department of Health Care Services at (800) 430-4263 {TTY: (800) 735-2922}, or visit https://www.healthcareoptions.dhcs.ca.gov/.

Blue Shield of California Promise Health Plan is a managed care organization, wholly owned by Blue Shield of California, offering Medi-Cal and Cal MediConnect Plans.

© 2002-2023. California Physicians’ Service DBA Blue Shield of California Promise Health Plan. All rights reserved.

California Physicians’ Service DBA Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association.

The provider network may change at any time. You will receive notice when necessary.

Blue Shield of California Promise Health Plan complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.

Blue Shield of California Promise Health Plan cumple con las leyes estatales y las leyes federales de derechos civiles vigentes, y no discrimina por motivos de raza, color, país de origen, ascedencial, religión, sexo, estado civil, genero, identidad de genero, orientación sexual, edad ni discapacidad.

Blue Shield of California Promise Health Plan 遵循適用的州法律和聯邦公民權利法律，並且不以種族、膚色、原國籍、血統、宗教、性別、婚姻 狀況、性別認同、性取向、年齡或殘障為由而進行歧視。

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Blue Shield of California Promise Health Plan, 601 Potrero Grande Drive, Monterey Park, CA 91755.

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