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 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 and Board (PDF, 326 KB)
- Long-Term Care Authorization Request (PDF, 2.9 MB)
- Non-Emergency Medical Transportation (NEMT) Physicians Certification Statement (PDF, 115 KB)
- Outpatient Treatment Authorization Request (PDF, 99 KB)
- Prescription Drug Prior Authorization and Step Therapy Exception Request (PDF, 1.4 MB)
- Servicing Provider Change Request Form for Existing Authorization (PDF, 99 KB)
- 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)
Claims and payments forms and templates
- 10-Day Notice Fax Cover Sheet (PDF, 74 KB)
- 274+ Flat File Sample (XLSX, 31 KB)
- Claims Fax Cover Sheet (PDF, 1 MB)
- EDI Inquiry Form (online)
- 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)
Delegation oversight forms
- Compliance Audit Evidence Grid (PDF, 280 KB)
- Delegation Oversight Newly Contracted Provider Training Attestation (PDF, 322, KB)
- Disclosure of Emerging Claim Deficiencies (PDF, 94 KB)
- Monthly Timeliness Report (Medi-Cal) (XLXS, 43 KB)
- Principal Officer Form (PDF, 46 KB)
- Provider Dispute Resolution Report (Commercial and Medi-Cal) (XLXS, 32 KB)
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)
Referral forms
- Beacon Health Options (Behavioral Health Services) Primary Care Physician Referral (PDF, 107 KB)
- Community Supports Referral (PDF, 302 KB)
- Cultural and Linguistically Appropriate Services Referral (PDF, 156 KB)
- Health Education Referral (PDF, 94 KB)
- Maternity Care Referral (PDF, 90 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, 150 KB)
- Appointment of Representative, Spanish (PDF, 335 KB)
- Critical Incident Report (PDF, 403 KB)
- Initial Health Appointment (IHA) Audit, Medi-Cal (PDF, 207 KB)
- Lead Declination Form, English (PDF, 136 KB)
- Lead Declination Form, Spanish (PDF, 122 KB)
- Notification of Extension for Use of Mental Health Care Information (PDF, 72 KB)
- Palliative Care Disenrollment Form (PDF, 61 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)
- Protocol for Requesting Interpretation Services (PDF, 80 KB)
- Provider Request Form for Medi-Cal Continuity of Care (PDF, 534 KB)
- Request for Release of Mental Health Care Information (PDF, 82 KB)
- 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.