No-Modal
Provider Forms & Documents
This page contains all the forms that may be needed by our providers. Member materials (e.g. Evidence of Coverage, Provider and Pharmacy Directory) can be found here:
Medi-Cal/Healthy Kids
Cal MediConnect
If you cannot find the form you need, please contact Provider Services.
Provider Forms
Astha
General/Uncategorized
Accommodation Check Sheet for Seniors and People with Disabilities
Advance Health Care Directive Form - Chinese
Advance Health Care Directive Form - English
Advance Health Care Directive Form - Spanish
Advance Health Care Directive Form - Tagalog
Advance Health Care Directive Form - Vietnamese
Authorized Representative Form
Authorized Representative Form (Español)
Authorized Representative Form (Tagalog)
Authorized Representative Form (Tiếng Việt)
Authorized Representative Form (中文)
Become a California Children's Services Provider
Bed Hold Authorization Request Form
CCS/GHPP Discharge Planning Service Authorization Request
Change Notification Form
Coordinated Care Initiative - Frequently Asked Questions (FAQs) for Providers
Delegate Notification Form
Early Start Referral Form
Health Education Referral Form (English)
Health Education Referral Form (Español)
Health Education Referral Form (Tagalog)
Health Education Referral Form (Tiếng Việt)
Health Education Referral Form (中文)
Letter of Interest - PCP
Letter of Interest - Specialist & Ancillary
Long-Term Care Discharge Notification Form
Medi-Cal Preventable Conditions Reporting Form
Medical Records Review Survey
Primary Care Facility Identification Form
Provider Dispute Form
W-9 Tax Form
Weekly Therapy Update Form
WIC Pediatric Referral
Grievance
Medi-Cal/Healthy Kids Member Grievance Form (English)
Medi-Cal/Healthy Kids Member Grievance Form (Español)
Medi-Cal/Healthy Kids Member Grievance Form (Tagalog)
Medi-Cal/Healthy Kids Member Grievance Form (Tiếng Việt)
Medi-Cal/Healthy Kids Member Grievance Form (中文)
Waiver of Liability Statement
Initial Health Assessments
Adult Questions by Age Group
Alternative Staying Health Assessment Tool Request Form
Behavioral Risk Topics - At-A-Glance
Instruction Sheet for Providers
Memo - New DHCS Requirements - Staying Healthy Assessment
Pediatric Questions by Age Group
Requirements for the Staying Healthy Assessment
Staying Health Assessment Provider Training (PPT)
Staying Healthy Assessment - 0-6 Months (English)
Staying Healthy Assessment - 0-6 Months (Español)
Staying Healthy Assessment - 0-6 Months (Tagalog)
Staying Healthy Assessment - 0-6 Months (Tiếng Việt)
Staying Healthy Assessment - 0-6 Months (中文)
Staying Healthy Assessment - 1-2 Years (English)
Staying Healthy Assessment - 1-2 Years (Español)
Staying Healthy Assessment - 1-2 Years (Tagalog)
Staying Healthy Assessment - 1-2 Years (Tiếng Việt)
Staying Healthy Assessment - 1-2 Years (中文)
Staying Healthy Assessment - 12-17 Years (English)
Staying Healthy Assessment - 12-17 Years (Español)
Staying Healthy Assessment - 12-17 Years (Tagalog)
Staying Healthy Assessment - 12-17 Years (Tiếng Việt)
Staying Healthy Assessment - 12-17 Years (中文)
Staying Healthy Assessment - 3-4 Years (English)
Staying Healthy Assessment - 3-4 Years (Español)
Staying Healthy Assessment - 3-4 Years (Tagalog)
Staying Healthy Assessment - 3-4 Years (Tiếng Việt)
Staying Healthy Assessment - 3-4 Years (中文)
Staying Healthy Assessment - 5-8 Years (English)
Staying Healthy Assessment - 5-8 Years (Español)
Staying Healthy Assessment - 5-8 Years (Tagalog)
Staying Healthy Assessment - 5-8 Years (Tiếng Việt)
Staying Healthy Assessment - 5-8 Years (中文)
Staying Healthy Assessment - 7-12 Months (English)
Staying Healthy Assessment - 7-12 Months (Español)
Staying Healthy Assessment - 7-12 Months (Tagalog)
Staying Healthy Assessment - 7-12 Months (Tiếng Việt)
Staying Healthy Assessment - 7-12 Months (中文)
Staying Healthy Assessment - 9-11 Years (English)
Staying Healthy Assessment - 9-11 Years (Español)
Staying Healthy Assessment - 9-11 Years (Tagalog)
Staying Healthy Assessment - 9-11 Years (Tiếng Việt)
Staying Healthy Assessment - 9-11 Years (中文)
Staying Healthy Assessment - Adult (English)
Staying Healthy Assessment - Adult (Español)
Staying Healthy Assessment - Adult (Tagalog)
Staying Healthy Assessment - Adult (Tiếng Việt)
Staying Healthy Assessment - Adult (中文)
Staying Healthy Assessment - Senior (English)
Staying Healthy Assessment - Senior (Español)
Staying Healthy Assessment - Senior (Tagalog)
Staying Healthy Assessment - Senior (Tiếng Việt)
Staying Healthy Assessment - Senior (中文)
Staying Healthy Assessment Training Attestation
Record Release Consent
Authorization for Release of Genetic Test Results
Authorization for Release of HIV/AIDS Test Results
Authorization for Release of Mental Health and/or Substance Abuse Records
General Authorization for Release of Medical Records
Authorization
2018 Cal MediConnect Prior Authorization Grid
2018 Medi-Cal and Healthy Kids Prior Authorization Grid
Bed Hold Authorization Request Form
Cal MediConnect List of Covered Drugs (Formulary)
Cal MediConnect Part D Coverage Determination Request
Case Management Referral Form
Long Term Care Notification Form
Medi-Cal Formulary
Prior Authorization Request - Medical Services
Prior Authorization Request - Prescription Drug
Transportation Physician Certification Statement
Mental Health & SCFHP/CMHD Forms
Benefit Year End Report
Healthy Kids SED Response Form
Mental Health Hospitalization Notification
Mental Health Services Flow Chart
Prior Authorization Cover Sheet
Prior Authorization Form
Prior Authorization Letter
Quarterly Report
SCFHP & CMHD Notification Form
SCFHP and CMHD Process (List of Attachments)
SCFHP, County Mental Health Department, Subcontractors
SCFHP/CMHD Definitions
SCFHP/CMHD Process
SCFHP/CMHD Requests for Assistance
Timely Access to Non-Emergency Health Care Services