PDF Forms and References in Alphabetical Order
- 30-Day Eligibility Report Medi-Cal 4682
- 60-Day Eligibility Report Medi-Cal 4683
- 90-Day Eligibility Report Medi-Cal 4685
- 120-Day Initial Health Assessment Report Medi-Cal 4681
- 837 5010 Professional and Institutional Standards EPO CMC Medi-Cal MEDICARE HMO 34284
- 837 Institutional Companion Guide CMC MEDICARE Medi-Cal HMO EPO 34285
- 837 Professional Companion Guide Medi-Cal EPO MEDICARE CMC HMO 34286
- AAP Recommendations for the Preventive Pediatric Health Care PPO Medi-Cal HSP HMO EPO 28346
- Activity Analysis Report HMO 4729
- Activity Analysis Report Field Descriptions HMO 14907
- Add Report Medi-Cal 4687
- Administration of Fluoride Varnish (PDF) MEDI-CAL CMC 500027a
- Adult AIDS/HIV Confidential Case Report HMO CMC PPO Medi-Cal HSP EPO MEDICARE 2738
- Adult Health Maintenance (PDF) MEDI-CAL CMC 500023q
- Adult Vaccine Administration Record (PDF) MEDI-CAL CMC 500023r
- Advance Directive Labels for Member Medical Record (PDF) MEDI-CAL CMC 500023v
- Advance Health Care Directives Info Sheet for English/Spanish (PDF) MEDI-CAL CMC 500023u
- After-Hours Sample Script - Arabic HSP CMC Medi-Cal HMO 27043
- After-Hours Sample Script - Armenian CMC Medi-Cal HSP HMO 27033
- After-Hours Sample Script - Chinese MEDICARE 43385
- After-Hours Sample Script - Chinese PPO HSP Medi-Cal CMC HMO EPO 43388
- After-Hours Sample Script - English (Medi-Cal CalViva) 27049
- After-Hours Sample Script - English (Medicare) 43381
- After-Hours Sample Script - English EPO CMC PPO Medi-Cal HMO HSP 43386
- After-Hours Sample Script - Farsi CMC HMO Medi-Cal HSP 27055
- After-Hours Sample Script - Hmong Medi-Cal 27047
- After-Hours Sample Script - Hmong CMC HMO Medi-Cal HSP 27048
- After-Hours Sample Script - Khmer (Cambodian) CMC HMO Medi-Cal HSP 27050
- After-Hours Sample Script - Korean HMO Medi-Cal CMC HSP 27051
- After-Hours Sample Script - Russian HMO CMC HSP Medi-Cal 27052
- After-Hours Sample Script - Spanish Medi-Cal 27062
- After-Hours Sample Script - Spanish MEDICARE 43384
- After-Hours Sample Script - Spanish PPO Medi-Cal EPO HMO CMC HSP 43387
- After-Hours Sample Script - Tagalog Medi-Cal HSP HMO CMC 27056
- After-Hours Sample Script - Vietnamese HMO HSP CMC Medi-Cal 27053
- Annual Care for Older Adults (COA)/Advance Care Planning (ACP) Form (PDF) Medicare 500072
- Appointment of Representative - Spanish CMC MEDICARE 39655
- Appointment of Representative Form MEDICARE CMC 26751
- Asthma Action Plan Medi-Cal 14858
- Appointments and Patient Recall (PDF) MEDI-CAL CMC 500023z
- Audometer Form (PDF) MEDI-CAL CMC 500025a
- AUDIT - English Medi-Cal 30816
- AUDIT - Spanish Medi-Cal 30817
- AUDIT-C - English Medi-Cal 30818
- AUDIT-C - Spanish Medi-Cal 30819
- Autoclave Maintenance and Run Log (PDF) MEDI-CAL CMC 500026m
- Autoclave Log CMC PPO EPO MEDICARE Medi-Cal HMO HSP 4760
- Bariatric Surgery Performance Centers HMO HSP PPO EPO 28064
- Blood and Body Fluid Exposure Report Form (PDF) MEDI-CAL CMC 500026b
- Breast Cancer Treatment Information Sign Medi-Cal 3386
- Bright Futures Promoting Oral Health (PDF) MEDI-CAL CMC 500027f
- Cancer Center (contracted) Medi-Cal
- Cancer Center (Contracted) CalViva
- Capitation Activity Analysis Report Field Descriptions CMC MEDICARE 14920
- Capitation Eligibility Summary Report by Group/Provider (BRM 11)MEDICARE CMC 14913
- Capitation Remittance Remittance Detail Report (BRM 20) MEDICARE CMC 14914
- Care Management Referral Form - CalViva Health Medi-Cal 33454
- Care Management Referral Form (PDF) - Medi-Cal 33432
- Care Management Referral Form - Commercial Medicare and CMC CMC PPO HSP EPO MEDICARE HMO MEDI-CAL33432
- CBAS Treatment Request Form Medi-Cal CMC 45833
- CBAS Treatment Request Form (CalViva Health) Medi-Cal 45834
- CCS Parent Notification Letter HMO Medi-Cal 5222
- CCS Program Application Medi-Cal HMO 5204
- CCS/GHPP Discharge Planning SAR Medi-Cal 34940
- Certification for Contracts Grants, loans, and Cooperative Agreements PPO HMO Medi-Cal HSP MEDICARE EPO 27811
- CHDP - Report of Health Exam for School Entry – English Medi-Cal 5503
- CHDP - Report of Health Exam for School Entry – Spanish Medi-Cal 5269
- CHDP Consent Form – English Medi-Cal 5267
- CHDP Consent Form – Spanish Medi-Cal 5268
- CHDP PM 160 INF Form Instructions Medi-Cal 25304
- CHDP PM 160 INF Form Instructions Medi-Cal 25588
- CHDP Program Code Conversion - Comprehensive Table Medi-Cal 44853
- CHDP Program Code Conversion Flyer - CalViva Health Medi-Cal 44855
- CHDP Program Code Conversion Flyer - Medi-Cal Medi-Cal 44854
- CHDS/CTCA Joint Guidelines for the Treatment of Active Tuberculosis Disease Medi-Cal 15136
- Checklist for Safe Vaccine Storage and Handling (PDF) MEDI-CAL CMC 500029a
- Child Abuse Reporting (PDF) MEDI-CAL CMC 500022k
- Chronic Condition Verification Form MEDICARE 24498
- Clean and Sanitary Environment (PDF) MEDI-CAL CMC 500021b
- Clinical Payment Policy CA.CP.MP.38 - Ultrasound in Pregnancy Medi-Cal 45793
- Clinical Payment Policy CP.MP.152 - Measurement of Serum 1 25-dihydroxyvitamin D HSP MEDICARE CMC Medi-Cal EPO PPO HMO 44247
- Clinical Payment Policy CP.MP.153 - Helicobacter Pylori Serology Testing MEDICARE PPO EPO HMO HSP Medi-Cal CMC 44248
- Clinical Payment Policy CP.MP.154 - Thyroid Hormones and Insulin Testing in Pediatrics HMO Medi-Cal EPO PPO CMC MEDICARE HSP 44249
- Clinical Payment Policy, CCP.MP.155 - EEG in the Evaluation of Headache PPO HSP EPO Medi-Cal HMO MEDICARE CMC 44250
- Clinical Payment Policy CP.MP.156 - Cardiac Biomarker Testing for Acute Myocardial Infarction HMO CMC MEDICARE HSP EPO PPO Medi-Cal 44261
- Clinical Payment Policy CP.MP.157 - 25-hydroxyvitamin D Testing in Children and Adolescents HSP PPO HMO CMC MEDICARE Medi-Cal EPO 44262
- Clinical Payment Policy CP.MP.38 - Ultrasound in Pregnancy HMO CMC MEDICARE EPO HSP PPO 45794
- Clorox Regular Bleach (PDF) MEDi-CAL CMC 500026i
- Cold Sterilization Log PPO MEDICARE Medi-Cal HMO EPO CMC 4761
- Commercial Electronic Media Format - Expanded Eligibility File ACE 42 HMO 4737
- Commercial Informational Letter to Member or Provider (Carve-out Situations) HMO 1073
- Confidential Morbidity Report PPO EPO MEDICARE HMO HSP CMC Medi-Cal 5716
- Confidentiality and Release of Information Form Medi-Cal 4271
- Confirmation of pregnancy form Medi-Cal 500191
- Confirmation of pregnancy form CalViva 500192
- Consent for Minors to Travel without an Escort (PDF) MEDI-CAL 50018
- Consent Form PM 330 (English) Medi-Cal 3477
- Consent Form PM 330 (Spanish) Medi-Cal 3480
- Consent to Treatment of Minor (PDF) MEDI-CAL CMC 500027d
- Contracted Cancer Centers (PDF)
- Contracted Cancer Centers (PDF) (CalViva Health)
- Controlled Substance Log Form (PDF) CMC MEDI-CAL 500024g
- Criteria for Hospice Appropriateness HMO MEDICARE CMC 17910
- Decision Power Referral Fax Form - CMC CMC 33431
- Decision Power Referral Fax Form - Commercial and Medicare HSP PPO EPO MEDICARE HMO 27223
- Decontamination of Surface (PDF) MEDI-CAL CMC 500026g
- Delegation of Service Agreement Supervision of Physician Assistance (PDF) MEDI-CAL CMC 500022c
- Dexa Scanner (PDF) MEDI-CAL CMC 500024i
- Diagnostic Evaluation/Assessment Form PPO 26888
- Diagnostic Procedures Requiring Prior Authorization for Health Net of California HMO MEDICARE PPO EPO 20540
- Direct Observation Therapy Referral Medi-Cal 5491
- Directory Removal for At-Risk Providers Form HMO HSP EPO Medi-Cal PPO 42604
- Directory Removal for At-Risk Providers Form (CalViva Health) Medi-Cal 42603
- Disclosure of Lobbying Activities Form and Disclosure Form Instructions HMO EPO MEDICARE Medi-Cal PPO HSP 27812
- Domestic Violence Reporting (PDF) MEDI-CAL CMC 500022o12
- Drug Use Questionnaire (DAST-20) Medi-Cal 5002
- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Coding Policies EPO Medicare Advantage HMO HMO HSP PPO 18270
- Durable Medical Equipment Prosthetics Orthotics and Supplies Coding Policies Medi-Cal 18271
- Edinburgh Perinatal/Postnatal Depression Scale (EPDS) Questionnaire (PDF) 500027e
- Elder Abuse Reporting (PDF) 500022n
- Electronic Eligibility File 277 Medi-Cal 4692
- Electronic Media Format Activity File HMO 4736
- Electronic Media Format Eligibility Summary by Group File HMO 4738
- Electronic Media Format Remittance Detail File HMO 4743
- Eligibility Listing Staff Model Roster Medi-Cal 4693
- Eligibility Report (BRM 42I) HMO 4730
- Eligibility Report (BRM 42P) - Professional HMO 14918
- Eligibility Report Field Descriptions EPO HMO PPO HSP Medi-Cal 14911
- Eligibility Report Field Descriptions MEDICARE CMC 14921
- Eligibility Summary by Group File MEDICARE CMC 4697
- Eligibility Summary by Group Report (BRM 13B) HMO 14915
- Eligibility Summary by Group and Provider Report Field Descriptions CMC MEDICARE 14922
- Eligibility Summary By Group Report Field Descriptions HMO 14909
- Eligibility Summary by Group/Provider Report HMO 4732
- Emergency Earthquake Plan (PDF) MCL CMC 500021g
- Emergency Fire Plan (PDF) MCL CMC 500021h
- Emergency Health Care Service (PDF) MCL CMC 5000021k
- Emergency Medication Dosage Chart (PDF) MCL CMC 500021l
- Energency Protocol (PDF) MCL CMC 500021m
- Emergency Response Worksheet (PDF) MCL CMC 500029b
- Emergency Supplies Inventory Checklist (PDF) MCL CMC 500021o
- Endoscopy Matrix Medi-Cal CMC HMO MEDICARE 30924
- EOC 300-308 Denied Claims Report sample Medi-Cal 28790
- Equipment Calibration Log CMC Medi-Cal 4644
- Equiment Transfer Log for Sterilzation (PDF) MCL CMC 500026n
- ESRD Medical Evidence Report MEDICARE CMC 2487
- Established CCS/GHPP Client SAR Medi-Cal 34339
- Expedited Organization Determination (EOD) MEDICARE 1356
- Facility Site Review Guidelines Medi-Cal CMC 4645
- Facility Site Review Tool CMC Medi-Cal 4646
- Fire Safety and Prevention and emergency Non-Medical Procedures (PDF) MCL CMC 200021e
- Fit Families for Life - Be In Charge - Program Referral Form Medi-Cal 25463
- Fit Families for Life - Be In Charge - Program Referral Form Medi-Cal 25570
- Freezer Temperature Log for Vaccines (Celsius) (PDF) MCL CMC 500024f
- Freezer Temperature Log for Vaccines (Fahrenheit) (PDF) MCL CMC 500024e
- Government Programs Electronic Media Format Activity File CMC MEDICARE 4698
- Government Programs Electronic Media Format Eligibility File MEDICARE CMC 4711
- Government Programs Electronic Media Format Member Status Table MEDICARE CMC 4714
- Government Programs Electronic Media Format Remittance Detail File CMC MEDICARE 4716
- Health Plan Interpreter Phone Numbers (PDF) MCL CMC 5500023h
- Hearing and Vision Graph (PDF) MCL CMC 500025b
- Hepatitis B Vaccination Declination CMC Medi-Cal HMO HSP MEDICARE EPO PPO 4762
- High-Risk Pregnancy Referral Form (CalViva) Medi-Cal 25613
- High-Risk Pregnancy Referral Form Medi-Cal 26165
- Hospice Consideration Request Letter CMC MEDICARE 13522
- Hospital Reinsurance Example CMC MEDICARE HMO 4459
- Hysterectomy - Informed Consent Medi-Cal 3390
- ICD-10-CM Codes for Abortion-Related Services (PDF) HMO PPO HSP EPO 500073
- Identification card (Cal MediConnect) (PDF) 30634
- Identification card (Elect Open Access) (PDF) 4467
- Identification card (HMO) (PDF) 4465
- Identification card (IFP Ambetter HMO HMO) (PDF) 29901
- Identification card (IFP Ambetter PPO) (PDF) 42412
- Identification card (Medi-Cal CalViva Health) (PDF) 22979
- Identification card (Medi-Cal mainstream) (PDF) 4490
- Identification card (Medi-Cal Molina Healthcare) (PDF) 4495
- Identification card (Medicare Advantage Seniority Plus) (PDF) 42414
- Identification card (Medicare Advantage Prescription Drug Plan) (PDF) 4481
- Identification card (Wellcare By Health Net) (PDF) 500047
- Identification card (Primary EPO) (PDF) 5865
- Identification card (PPO) (PDF) 4476
- Identification card (PureCare Large group) (PDF) 500050
- Identification card (Select POS) (PDF) 4468
- Individualized Care Plan (ICP) - Directions Medi-Cal 3471
- Industry Collaboration Effort (ICE): Provider Tools to Care for Diverse Populations HMO PPO HSP EPO Medi-Cal MEDICARE 15052
- Industry Collaboration Effort (ICE): Provider Tools to Care for Diverse Populations - CalViva Health Medi-Cal 30864
- Industry Collaboration Effort (ICE): Provider Tools to Care for Diverse Populations - CMC CMC 39575
- Infant Nutrition Benefit Authorization Request Form: Therapeutic Formula Medi-Cal 24681
- Infant Nutrition Benefit Authorization Request Form: Therapeutic Formula (CalViva Health) Medi-Cal 28162
- Infant Nutrition Benefits Authorization Request Form: Breast Pump and Lactation Consultant Services Medi-Cal 24670
- Infant Nutrition Benefits Authorization Request Form: Breast Pump and Lactation Consultant Services (CalViva Health) Medi-Cal 43284
- Infant Nutrition Benefits Provider Guide Medi-Cal 24682
- Infant Nutrition Benefits Provider Guide - CalViva Health Medi-Cal 24683
- Informed Consent and Human Sterilization Consent (PDF) MCL CMC 500022q
- Injectable Medication HCPCS/DOFR Crosswalk HMO CMC MEDICARE Medi-Cal 5795
- Inpatient California Health Net Commercial Prior Authorization (PDF) HMO PPO EPO HSP CMC 50011
- Inpatient California Medi-Cal Prior Authorization (PDF) (CalViva Health) MEDI-CAL 50013
- Inpatient California Medi-Cal Prior Authorization (PDF) MEDI-CAL 500030
- Inpatient California Health Net Medicare Prior Authorization Form (PDF) MEDICARE 50015
- Instrument Sterilization (PDF) MCL CMC 5000026L
- Interpreter Quality Standards Guidance and Requirements (PDF) MCL CMC 500023k
- Interpreter Services (PDF) MCL CMC 500023n
- Interpreter Service Quick Reference Card EPO Medi-Cal HMO PPO MEDICARE HSP 39281
- Interpreter Service Quick Reference Card (Cal Medi-Connect) CMC 39282
- Interpreter Service Quick Reference Card (CalViva) Medi-Cal 39283
- Interpreters Available Poster (PDF) CalViva Health 500023j
- Interpreters Available Poster (PDF) MCL CMC500023m
- Jade-C SNP MEDICARE 44233
- Laboratory Services (PDF) MCL CMC 500024a
- Language Assistance Notice Medi-Cal 29855
- Language Assistance Notice - CalViva Medi-Cal 29854
- Language Identification Poster MEDICARE CMC Medi-Cal PPO HMO HSP EPO 39256
- Language Identification Poster - CalViva Medi-Cal 29856
- Language Proficiency Assessment Resources (PDF) MCL CMC 500023l
- Linkage/Enrollment Tracking Log for Initial Health Assessment Medi-Cal 4522
- Long-Term Care Authorization Notification Form Medi-Cal CMC 32008
- Long-Term Care Authorization Notification Form CalViva 500074
- Los Angeles County CCS Fax Cover Sheet Medi-Cal 34370
- Los Angeles County Department of Health Services (LA-DHS) Participating Physician Groups Medi-Cal 30114
- Marketing Guidelines for Providers Serving CalViva Health Medi-Cal Members Medi-Cal 45880
- Marketing Guidelines for Providers Serving Medi-Cal Members Medi-Cal 45881
- Medical and Lab Equipment Maintenance (PDF) MCL CMC 500021j
- Medical Assistance Certification (PDF) MCL CMC 500022g
- Medical Assistance Training Letter (PDF) MCL CMC 500022f
- Medical Assistance Venipuncture Certification (PDF) MCL CMC 500022h
- Medical Records (PDF) MCL CMC 500023o
- Medical Record - Adult Health Maintenance Checklist With Standards EPO MEDICARE HMO PPO HSP 4484
- Medical Record - Advance Directive Labels HMO EPO HSP PPO MEDICARE 4486
- Medical Record - Audiometric Screening MEDICARE HMO HSP EPO PPO 4587
- Medical Record - History Spanish HMO MEDICARE PPO HSP EPO 4509
- Medical Record - Medication and Chronic Problem Summary PPO HSP EPO HMO MEDICARE 4516
- Medical Record Review Tool CMC Medi-Cal 4597
- Medical Record Review Guidelines Medi-Cal 4598
- Medical Record - Signature Page EPO MEDICARE PPO HSP HMO 4519
- Medical/Behavioral Comanagement/Coordination of Care Form EPO HSP HMO CMC PPO MEDICARE 14745
- Medical Waste Collection Tracking Log (PDF) MCL CMC 500026f
- Medical Waste Log Sheet (PDF) 500026e
- Medicare and Medicare-Medicaid Plans Prescription Claim Form CMC MEDICARE 15471
- Medicare Capitation Activity Analysis Report (BRM 30) MEDICARE CMC 14919
- Medicare Informational Letter to Patient and/or Provider/Physician CMC MEDICARE 26235
- Medicare Member Claim Form MEDICARE CMC 35691
- Medicare Prior Authorization -Formulary Exception Request Fax Form MEDICARE 31898
- Medicare Provider Termination Notification Template MEDICARE CMC 26580
- Medicare Seniority Plus MEDICARE 42414
- Member Complaint Log (PDF) MCL CMC 500023g
- Member Instructions for Post-Emergency Room Care Medi-Cal 3141
- Member Grievance Acknowledgement Letter Medi-Cal 2314
- Member Grievance Form HMO HSP 2279
- Member Grievance/Complaint Form - Arabic (PDF) Medi-Cal 25672
- Member Grievance/Complaint Form - Armenian (PDF) Medi-Cal 25628
- Member Grievance/Complaint Form - Chinese (PDF) Medi-Cal 25629
- Member Grievance/Complaint Form - English (PDF) Medi-Cal 25612
- Member Grievance/Complaint Form - Farsi (PDF) Medi-Cal 25630
- Member Grievance/Complaint Form - Hindi (PDF) Medi-Cal 500023a
- Member Grievance/Complaint Form - Hmong (PDF) Medi-Cal 25631
- Member Grievance/Complaint Form - Japanese (PDF) Medi-Cal 500023b
- Member Grievance/Complaint Form - Khmer (PDF) Medi-Cal 25632
- Member Grievance/Complaint Form - Korean (PDF) Medi-Cal 25633
- Member Grievance/Complaint Form - Loation (PDF) Medi-Cal 500023c
- Member Grievance/Complaint Form - Panjabi PDF) Medi-Cal 500023d
- Member Grievance/Complaint Form - Russian (PDF) Medi-Cal 25634
- Member Grievance/Complaint Form - Spanish (PDF) Medi-Cal 25742
- Member Grievance/Complaint Form - Tagalog (PDF) Medi-Cal 25636
- Member Grievance/Complaint Form - Thai (PDF) Medi-Cal 500023e
- Member Grievance/Complaint Form - Vietnamese Medi-Cal 25637
- Member Grievance/Compliane Form - English (CalViva) (PDF) Medi-Cal 25611
- Member Grievance/Compliane Form - Hmong (CalViva) (PDF) Medi-Cal 25743
- Member Grievance/Compliane Form - Spanish (CalViva) (PDF) Medi-Cal 25635
- Member Grievance/Complaint Form (PDF) 500023f
- Miscellaneous Coding Policies Medi-Cal 12987
- Minor's Rights to Sensitive Services (PDF) MCL CMC 500022r
- Molina Service Request Form Medi-Cal 3524
- Monthly Equipment and Medication Replacement log (PDF) MCL CMC 500021n
- Monthly Medication and Lab Supplies Inventory Checklist (PDF) MCL CMC 500021p
- New Referral CCS/GHPP Client SAR HMO Medi-Cal 5216
- NICU Level of Care Criteria HSP HMO PPO 4229
- Non-discrimination Notice and Taglines PPO EPO HSP HMO 18609
- Non-discrimination Notice and Taglines (CalViva) Medi-Cal 39219
- Non-discrimination Notice and Taglines - Hmong (CalViva) Medi-Cal 500032
- Non-discrimination Notice and Taglines - Spanish (CalViva) Medi-Cal 500033
- Non-discrimination Notice and Taglines Medi-Cal 39220
- Non-discrimination Notice and Taglines - Arabic Medi-Cal 500034
- Non-discrimination Notice and Taglines - Armenian Medi-Cal 500035
- Non-discrimination Notice and Taglines - Cambodian Medi-Cal 500036
- Non-discrimination Notice and Taglines - Chinese Medi-Cal 500037
- Non-discrimination Notice and Taglines - Farsi Medi-Cal 500038
- Non-discrimination Notice and Taglines - Hmong Medi-Cal 500039
- Non-discrimination Notice and Taglines - Korean Medi-Cal 500040
- Non-discrimination Notice and Taglines - Russian Medi-Cal 500041
- Non-discrimination Notice and Taglines - Spanish Medi-Cal 500042
- Non-discrimination Notice and Taglines - Tagalog Medi-Cal 500043
- Non-discrimination Notice and Taglines - Vietnamese Medi-Cal 500044
- Non-discrimination Notice and Taglines CMC 39221
- Non-discrimination Notice and Taglines MEDICARE 39255
- Non-Physician Medical Practitioners (PDF) MCL CMC 500022b
- Notice of Action Letter Translations and Alternate Formats: Akorbi Plunet Portal Guide (PDF) Medi-Cal 500048
- Notice of Action Letter Translations and Alternate Formats: Akorbi Plunet Portal Guide (CalViva) (PDF) Medi-Cal 500049
- Notice of Action Letter Translations and Alternate Formats: Akorbi Plunet Portal Guide (PDF) CMC 500067
- Office Cleaning Schedule (PDF) MCL CMC 500021c
- Office Cleaning Log/Schedule Year (PDF) MCL CMC 500021d
- Offshore Subcontracting Attestation: Participating Provider MEDICARE EPO PPO HMO HSP CMC Medi-Cal 35773
- Oral Health Risk Assessment Tool (PDF) MCL CMC 500027g
- Order of Benefits for Dependent Children HMO HSP 3909
- Out-of-Pocket Maximum - Back HSP HMO 2313
- Out-of-Pocket Maximum - Front HSP HMO 3578
- Out-of-Pocket Maximum Copayment Example HMO HSP 14478
- Outpatient California Health Net Commercial Prior Authorization (PDF) HMO PPO EPO HSP 50012
- Outpatient California Medi-Cal Prior Authorization (PDF) (CalViva Health) MEDI-CAL 50014
- Outpatient California Medi-Cal Prior Authorization (PDF) MEDI-CAL 500031
- Outpatient California Health Net Medicare Prior Authorization Form (PDF) MEDICARE 50016
- Palliative Care Referral Form Medi-Cal 45862
- Palliative Care Referral Form (CalViva Health) 45863
- Payment Integrity Policy CC.PP.007 - Maximum Units of Service HSP EPO MEDICARE HMO Medi-Cal PPO CMC 45791
- Payment Integrity Policy CC.PP.054 - Physician's Consultation Services Medi-Cal 43111
- Payment Integrity Policy CC.PP.055 - Physician's Office Lab Testing Medi-Cal 45792
- Payment Integrity Policy CC.PP.056 - Urine Specimen Validity Testing HSP PPO EPO HMO CMC MEDICARE Medi-Cal 44934
- Payment Integrity Policy CC.PP.063 - Place of Service Mismatch HSP HMO CMC Medi-Cal MEDICARE EPO PPO 44935
- Payment Integrity Policy CC.PP.068 Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services HSP HMO CMC Medi-Cal MEDICARE EPO PPO 50009
- Payment Integrity Policy CC.PP.069 Multiple Procedure Reduction: Ophthalmology HSP HMO CMC Medi-Cal MEDICARE EPO PPO 50010
- Payment Integrity Policy CC.PP.501 30 day Readmission Medi-Cal CMC PPO MEDICARE HSP HMO EPO 46279
- Payment Integrity Policy HNCA.PP.053 - Leveling of Emergency Room Services PPO HSP MEDICARE Medi-Cal CMC HMO EPO 45999
- PDR Overturn Letter MEDICARE 30898
- PDR Uphold Letter MEDICARE 30899
- Pediatric Health Maintenance Checklist (PDF) MCL CMC 500023t
- Perinatal Notification and Assessment Report (Kern, San Juaquin and Stanislaus) (PDF) 26514 MCL
- Perinatal Notification and Assessment Report (Los Angeles, San Diego, Sacramento, Riverside, San Berbardino and Tulare) (PDF) 26515 MCL
- Personnel and Staff Training (PDF) MCL CMC 500022i
- Pharmaceutical Services (PDF) MCL CMC 500024b
- Physical Accessibility Review Survey (FSR Attachment C) CMC Medi-Cal 28785
- Physical or Speech Therapy MEDICARE PPO EPO HMO HSP 21450
- Physician Certification Statement Form - Request for Transportation (PDF) MEDI-CAL 5000
- Physician Certification Statement Form - Request for Transportation (PDF) CalViva Health MEDI-CAL 5001
- Physician Certification Statement Form - Request for Transportation (PDF) CMC 5002
- Policy and Procedure: Individual Health Education Behavioral Assessment (IHEBA) - CMC CMC 44411
- Policy and Procedure: Staff Qualifications Medi-Cal CMC 4673
- Policy and Procedure: Standard and Universal Precautions CMC Medi-Cal 4661
- Potential Quality Issue Referral Form Medi-Cal 25465
- Potential Quality Issue Referral Form CMC HMO Medi-Cal MEDICARE PPO EPO HSP 25616
- PPG Professional Batch Form EPO HMO 1248
- PPG OOPM Notification Letter - Hospitalization HMO 3591
- Pre-qualification Assessment Tool MEDICARE 40491
- Preventive Care Physican Examination Form - 1 month: and Under Infants (PDF) CMC MCL 500028e
- Preventive Care Physican Examination Form - 1 - 2 months: Infants (PDF) CMC MCL 500028a
- Preventive Care Physican Examination Form - 3 - 4 months: Infants (PDF) CMC MCL 500028b
- Preventive Care Physican Examination Form - 5 - 6 months: Infants (PDF) CMC MCL 500028c
- Preventive Care Physican Examination Form - 7 - 9 months: Infants (PDF) CMC MCL 500028d
- Preventive Care Physican Examination Form - 10 - 11 months: Infants (PDF) CMC MCL 500028v
- Preventive Care Physican Examination Form - 12 - 15 months: Toddlers (PDF) CMC MCL 500028f
- Preventive Care Physican Examination Form - 16 - 23 months: Toddlers (PDF) CMC MCL 500028g
- Preventive Care Physican Examination Form - 2 years: Children (PDF) CMC MCL 500028h
- Preventive Care Physican Examination Form - 2 1/2 years (30 months): Children (PDF) CMC MCL 500028m
- Preventive Care Physican Examination Form - 3 years: Children (PDF) CMC MCL 500028i
- Preventive Care Physican Examination Form - 4 - 5 years: Children (PDF) CMC MCL 500028j
- Preventive Care Physican Examination Form - 6 - 8 years: Children (PDF) CMC MCL 500028k
- Preventive Care Physican Examination Form - 9 - 12 years: Children (PDF) CMC MCL 500028l
- Preventive Care Physican Examination Form - 13 -16 years: Teens (PDF) CMC MCL 500028n
- Preventive Care Physican Examination Form - 17 - 20 years: Teens (PDF) CMC MCL 500028o
- Preventive Care Physican Examination Form - 21 - 39 years female: Adults (PDF) CMC MCL 500028p
- Preventive Care Physican Examination Form - 21 - 39 years male: Adults (PDF) CMC MCL 500028q
- Preventive Care Physican Examination Form - 40 - 49 years female: Adults (PDF) CMC MCL 500028r
- Preventive Care Physican Examination Form - 40 - 49 years male: Adults (PDF) CMC MCL 500028s
- Preventive Care Physican Examination Form - 50+ years female: Adults (PDF) CMC MCL 500028t
- Preventive Care Physican Examination Form - 50+ years male: Adults (PDF) CMC MCL 500028u
- Preventive Services Screening and Equipment (PDF) MCL CMC 500025c
- Prescription Drug Prior Authorization or Step Therapy Exception Form HMO EPO PPO Medi-Cal HSP 31463
- Prior Authorization/Referrals (PDF) MCL CMC 500022s
- Primary Care Services Eligible for Primary Care Incentive Payments in Calendar Year 2011 CMC MEDICARE 25244
- Primary Language Assessment Labels (PDF) MCL CMC 500023i
- Prior Authorization Requirements (Commercial and Medicare) HMO PPO MEDICARE EPO 32007
- Prior Authorization Requirements CMC 29766
- Prior Authorization Requirements (fee-for-service) Medi-Cal 23910
- Prostate Cancer Treatment Information Sign CMC PPO MEDICARE Medi-Cal HMO EPO 3388
- Provider CMC Marketing Material Checklist CMC 32907
- Provider Dispute Resolution Request - CalViva Health Medi-Cal 25602
- Provider Dispute Resolution Request - Commercial and Medi-Cal EPO Medi-Cal HMO HSP PPO 42462
- Provider Dispute Resolution Request - IFP HMO HSP EPO PPO 42461
- Provider Dispute Resolution Request - Medicare MEDICARE CMC 42463
- Provider Medicare Marketing Material Review Submission Check List MEDICARE 32905
- Provider Order Form for Health Education Materials (CalViva Health) Medi-Cal 25604
- Provider Order Form for Health Education Materials Medi-Cal 25622
- Provider Order Form for Health Education Materials CMC 30515
- Provision of Service 24 Hours a day (PDF) MCL CMC 500023x
- Quick Reference Guide PPO HMO EPO MEDICARE HSP 14361
- Quick Reference Sheet MEDICARE CMC 1220
- Radiology Health Branch Contact Info (PDF) MCL CMC 500024j
- Radiology Services (PDF) MCL CMC 500024h
- Reconstructive Surgery Decision Tree HMO CMC EPO Medi-Cal MEDICARE 19813
- Red Flags for Alcohol/Drug Abuse Medi-Cal 5005
- Referral Tracking Log (PDF) MCL CMC 500023i
- Refrigerator Temperature Log for Vaccines (Celsius) (PDF) MCL CMC 500024d
- Refrigerator Temperature Log for Vaccines (Fahrenheit) (PDF) MCL CMC 500024c
- Reinstatement Notice for Skilled Nursing Facility - Continued Stay HMO 1072
- Remittance Detail Report (BRM 12A) HMO 4735
- Remittance Detail Report Field Descriptions HMO 14912
- Remittance Detail Report Field Descriptions MEDICARE CMC 14910
- Reopen Request Form MEDICARE 31149
- Reportable Diseases HMO HSP MEDICARE Medi-Cal PPO CMC EPO 2715
- Report of Suspected Dependent Adult/Elder Abuse Form and General Instructions (PDF) MCL CMC 500022n
- Request for Confidential Communication Form PPO HSP EPO HMO 34132
- Request for PCP/PPG Change Form Medi-Cal 25603
- Request for PCP/PPG Change Form Medi-Cal 31986
- Request for PCP/PPG Change Form CalVival (Spanish) Medi-Cal 31984
- Request for PCP/PPG Change Form (Spanish) Medi-Cal 31985
- Respite Care Referral Form CMC 46184
- Sample - Hospital Refusal Letter (PDF) HMO HSP EPO 2726
- Sample Site Evacuation Plan (PDF) MCL CMC 500021i
- SB 260 Reconciliation Report (BRM_28) CMC MEDICARE 4725
- SB 260 Reconciliation Report Format Exhibits I-II MEDICARE CMC 4723
- Shared-Risk Settlement Example CMC HMO MEDICARE 20169
- Sharps Injury Log (PDF) MCL CMC 500026c
- Site Accessibility by Individuals with Physical Disabilities (PDF) MCL CMC 500021a
- Skin Cancer Screening Form (PDF) MCL CMC 500023w
- Special Risk Pool Claims Submission HMO 2417
- Special Risk Pool Member Identifier HMO 2416
- Spill Kit Information (PDF) MCL CMC 500026d
- Staff Education Checklist (PDF) MCL CMC 500022j
- Staff Qualifications (PDF) MCL CMC 500022a
- Staff Signature Page Form for Member Medical Records (PDF) MCL CMC 500023p
- Standard of Care Guidelines for Childhood Lead Screening (PDF) MCL CMC 500027c
- Standardized Procedures Requorements for Nurse Practitioners Practice (PDF) MCL CMC 500022d
- Standardized and Universal Precautions (PDF) MCL CMC 500026k
- State Health Programs Provider Inquiry Spreadsheet Medi-Cal 26598
- Sterilization Procedures Log Medi-Cal 3469
- Subscriber OOPM Notification Letter HSP HMO 3603
- Supervising PA PAC Document (PDF) MCL CMC 500027h
- Suspected Child Abuse Report (PDF) MCL CMC 500022k
- Suspected Injury Report Form (PDF) MCL CMC 500022p
- T-ACE Medi-Cal 5007
- TB Risk Assessment - English/Spanish (PDF) MCL CMC 500027b
- Transfer or Termination Incident Report HMO 3234
- Transfer or Termination Incident Report - MEDICARE CMC MEDICARE HMO 11029
- Transition of Care Assistance Request Form CMC MEDICARE 15121
- Transplant Request - BMT/PBSCT HMO MEDICARE CMC 3788
- Transplant Request - Heart MEDICARE HMO CMC 3789
- Transplant Request - Heart/Lung MEDICARE HMO CMC 3790
- Transplant Request - Kidney HMO MEDICARE CMC 3792
- Transplant Request - Kidney/Pancreas CMC MEDICARE HMO 3794
- Transplant Request - Liver HMO CMC MEDICARE 3791
- Transplant Request - Lung HMO MEDICARE CMC 3793
- Transplant Performance Centers MEDICARE Medi-Cal HSP HMO PPO EPO 28603
- Transplant Review Process Phase I - Internal Review HMO 3786
- Transplant Review Process Phase II - External Review HMO 3785
- Triage (PDF) MCL CMC 500023ab
- Tuberculosis Suspect Case Report Medi-Cal 5492
- Tuberculosis Suspect Case Report - Tulare 5494
- TWEAK Test Medi-Cal 5010
- Type 1-APTC Pend Claim Letter HMO 34116
- Type 3A-APTC Primary Care Physicians (PCP)/PPG Letter HMO 34117
- Type 3B-APTC Claims Look-Back Letter HMO 34118
- Type 4-APTC Authorization Rescind Letter HMO 34119
- Type 5-APTC Inpatient Authorization Rescind Letter HMO 34120
- Ultra Clorox Germicidal Bleach (PDF) MCL CMC 500026i
- Understanding Bleach (PDF) MCL CMC 500026h
- Unlicensed Personnel (PDF) MCL CMC 5000223
- Urgent Request for Continuing Home Health Services HMO PPO EPO CMC HSP MEDICARE 21449
- Urgent Request for Continuing Occupational, Physical or Speech Therapy (PDF) HMO PPO EPO CMC HSP MEDICARE 21450
- Utilization Management Timeliness Standards - Commercial EPO HMO PPO 21439
- Utilization Management Timeliness Standards - Medi-Cal Medi-Cal CMC 21441
- Utilization Management Timeliness Standards - Medicare CMC MEDICARE 21440
- Weekly Inpatient Denial Log Sheet (PDF) HMO CMC MEDICARE 15747
- WIC Pediatric Referral Form Medi-Cal 5460
- WIC Referral for Postpartum-Breastfeeding Women Medi-Cal 5461
- WIC Referral for Pregnant Women Medi-Cal 5462
- Women's Folic Acid (PDF) MCL CMC 500027i
- Workplace Violence Protocol (PDF) MCL CMC 500021f