Forms and 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:
If you cannot find the form you need, please contact Provider Network Operations.
This page contains PDFs that require Adobe Acrobat Reader to be installed on your system.
Download forms
- Access to Care Training Attestation
- Accommodation Check Sheet for Seniors and People with Disabilities
- Advance Healthcare Directive Form (English)
- Advance Healthcare Directive Form (Spanish)
- Advance Healthcare Directive Form (Vietnamese)
- Advance Healthcare Directive Form (Simplified Chinese)
- Advance Healthcare Directive Form (Tagalog)
- Authorized Representative Form (English)
- Authorized Representative Form (Spanish)
- Authorized Representative Form (Vietnamese)
- Authorized Representative Form (Simplified Chinese)
- Authorized Representative Form (Tagalog)
- Become a California Children's Services Provider
- Blood Lead Testing Guidance - CDPH
- California Management Guidelines on Childhood Lead Poisoning for Health Care Providers
- CCS/GHPP Discharge Planning Service Authorization Request
- Change Notification Form
- Contracted DME and Medical Supply Vendor List
- Coordinated Care Initiative—Frequently Asked Questions (FAQs) for Providers
- DME Order Form
- Diabetes Prevention Program Referral Form
- Early Start Referral Form
- Echo Health - EFT and ERA (835) Enrollment Form
- Health Risk Assessment Form (English)
- Health Risk Assessment Form (Spanish)
- Health Risk Assessment Form (Vietnamese)
- Health Risk Assessment Form (Simplified Chinese)
- Health Risk Assessment Form (Tagalog)
- Healthy Moms Healthy Babies Program Enrollment Form
- Lead Screening Monitoring Standing Order
- Lead Screening in Children Tip-Sheet
- Letter of interest
- Long-Term Care Discharge Notification Form
- Medi-Cal Preventable Conditions Reporting Form
- Medication Reconciliation Post Discharge Form
- Potential Quality of Care Issue (PQI) Referral Form
- Provider Dispute Form
- Provider Dispute Form—Multiple "Like" Claims
- Request Health Education for Patient
- Standard of Care Guidelines on Childhood Lead Poisoning for California Health Care Provider
- Timely Access to Care Standards
- W-9 Tax Form
- Weekly Therapy Update Form
- WIC Pediatric Referral
- Medical Benefit Drug Prior Authorization Grid
- Medical Covered Services Prior Authorization Grid
- Bed Hold Authorization Request Form
- Bed Hold Authorization Request Form FAQs
- DualConnect List of Covered Drugs (Formulary)
- DualConnect Part D Coverage Determination Request
- Case Management Referral Form
- DME Specialty Device List
- Health Homes Program Referral Form
- Long-Term Care Authorization Form
- Long-Term Care Authorization Form FAQs
- Medi-Cal Prior Authorization Requirements
- Prior Authorization Request—Medical Services
- Prior Authorization Request—Prescription Drug
- Transportation Physician Certification Statement