Provider Forms list for both secure and non-secure sections

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Provider Forms

All Forms are in pdf Format

Consent Forms:

General Forms:

Member Grievance Form - Medi-Cal - English
Member Grievance Form - Medi-Cal - Spanish
Member Grievance Form - Medi-Cal - Vietnamese
Member Grievance Form - Healthy Families & Healthy Kids - English
Member Grievance Form - Healthy Families & Healthy Kids - Spanish
Member Grievance Form - Healthy Families & Healthy Kids - Vietnamese
Non-formulary Drug Review Request Form ( please indicate which formulary (Medi-Cal or Healthy Generations) when you submit the form.)
Provider Change Notification Form

Medical Record Forms:
(One-page documnets are available in the Secure Provider Section)

Secure Forms: * The following forms are available to our providers through our password-protected Secure Site. If you do not have a User ID and password for our Secure Site, contact the Provider Services Department. *
Authorization Forms: Notification of Estimated Date of Confinement (EDOC) MedImpact RX Drug Prior Authorization Request Prior Authorization Request Referral Authorization Form (RAF) Health Education Forms: Health Education Referral Form Miscellaneous Forms: Early Start Program WIC Program
Well Visit Forms:
Pediatric and Adolescent: Newborn to 1 Week Age 2 to 4 Weeks Age 2 Months Age 4 Months Age 6 Months Age 9 Months Age 12 Months Age 15 Months Age 18 Months Age 2 Years Age 3 Years Ages 4 to 5 Years Ages 6 to 8 Years Ages 9 to 11 Years Ages 12 to 21 Years	Adult: Ages 22 to 39 Years Ages 40 to 64 Years Ages 65 Years Adult Preventive Guideline Dates of Service Form