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
- Applied Behavioral Analysis Referral Form (PDF, 399 KB)
- Community-Based Adult Services (CBAS) Inquiry (PDF, 266 KB)
- Community-Based Adult Services (CBAS) Treatment Authorization Request (PDF, 807 KB)
- Community Health Worker Benefit Extension Request Form (PDF, 519 KB)
- Community Health Worker Recommendation Form (PDF, 535 KB)
- DME Treatment Authorization Request (PDF, 201 KB)
- Healthcare Professional/Physician Administered Drug Requests (medical benefit drugs) (PDF, 67 KB)
- Home Health Treatment Authorization Request (PDF, 216 KB)
- Intermediate Care Facility – Developmentally Disabled Treatment Authorization Request (PDF, 327 KB)
- Long-Term Care Custodial Authorization Request – Room and Board (PDF, 528 KB)
- Non-Emergency Medical Transportation (NEMT) Physicians Certification Statement (PDF, 57 KB)
- Servicing Provider Change Request Form for Existing Authorization (PDF, 125 KB)
- Skilled Nursing Facility Service Authorization Request (PDF, 467 KB)
- Treatment Authorization Request for Medi-Cal Members (PDF, 859 KB)
Claims and payments forms and templates
- 10-Day Notice Fax Cover Sheet (PDF, 99 KB)
- 274+ Flat File Sample (XLSX, 31 KB)
- Billing Guide for ICF/DD Facilities Effective 2/1/24 (PDF, 162 KB)
- Billing Guide for LTC Facilities Effective 2/1/24 (PDF, 161 KB)
- Claims Fax Cover Sheet (PDF, 1 MB)
- SNF Claims Billing Guide DOS Prior to 2/1/24 (PDF, 323 KB)
Delegation oversight forms
- Compliance audit evidence grid (PDF, 313 KB)
- Delegation oversight newly contracted provider training attestation (PDF, 120 KB)
- Delegation oversight newly contracted provider training attestation – Specialty health plan/vendor (PDF, 121 KB)
- Disclosure of emerging claim deficiencies (PDF, 94 KB)
- Monthly timeliness report (Medi-Cal) (XLXS, 43 KB)
- Principal officer form – Claims primary and alternate (PDF, 113 KB)
- Principal officer form — Dual claims and PDR (PDF, 125 KB)
- Principal officer form — PDR primary and alternate (PDF, 124 KB)
- Provider dispute resolution report (Commercial and Medi-Cal) (XLXS, 32 KB)
Provider dispute forms
- Provider dispute resolution request (PDF, 159 KB)
- Provider dispute resolution request (multiple claims) spreadsheet (PDF, 116 KB)
Referral forms
- Community supports referral (PDF, 321 KB)
- Cultural and linguistically appropriate services referral (PDF, 1 MB)
- Health education referral (PDF, 113 KB)
- Maternity care referral (PDF, 231 KB)
- Medi-Cal Social Services and mental health referral form (PDF, 254 KB)
- Population Health Management/Case Management referral (PDF, 304 KB)
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)
- Blue Shield Promise PPC/HCAC submission form (PDF, 187 KB)
- Clinical trial Medicaid attestation form (PDF, 135 KB)
- Critical incident report (PDF, 165 KB)
- Initial health appointment (IHA) Audit, Medi-Cal (PDF, 277 KB)
- Lead declination form, English (PDF, 136 KB)
- Lead declination form, Spanish (PDF, 122 KB)
- Medical assistant certificate (PDF, 122 KB)
- Palliative care patient eligibility screening tool (PDF, 271 KB)
- Palliative care recertification tool (PDF, 98 KB)
- Pregnancy notification form — Medi-Cal patients (PDF, 196 KB)
- Protocol for requesting interpretation services (PDF, 465 KB)
- Provider request for continuity of care (PDF, 1 MB)
- Request/Refusal for interpretive services (PDF, 69 KB)
- Request/Refusal for interpretive services (Spanish) (PDF, 68, KB)
- Request/Refusal for interpretive services (Threshold languages) (PDF, 991, KB)
Medical care solutions
Review medical care solutions for Blue Shield Promise plans.
Prior authorization list
View the list of medical services and procedures requiring medical necessity review or supplemental documentation prior to payment.