PDF Forms and References in Alphabetical Order

# | A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

#

• 837 5010 Professional and Institutional Standards (PDF) 
• 837 Institutional Companion Guide (PDF) 
• 837 Professional Companion Guide (PDF)

A

• Administration of Fluoride Varnish (PDF)
• Advance Directive Labels for Member Medical Record (PDF)  
• Advance Health Care Directives Info Sheet for English/Spanish (PDF)
• Adult AIDS/HIV Confidential Case Report (PDF)
• Adult Health Maintenance (PDF)
• Adult Vaccine Administration Record (PDF)
• After-Hours Sample Script - Arabic (PDF)
• After-Hours Sample Script - Armenian (PDF)
• After-Hours Sample Script - Chinese (PDF)
• After-Hours Sample Script - English (PDF) 
• After-Hours Sample Script - Farsi (PDF)
• After-Hours Sample Script - Hmong (PDF) 
• After-Hours Sample Script - Khmer (Cambodian) (PDF)
• After-Hours Sample Script - Korean (PDF)
• After-Hours Sample Script - Russian (PDF)
• After-Hours Sample Script - Spanish (PDF)
• After-Hours Sample Script - Tagalog (PDF)
• After-Hours Sample Script - Vietnamese (PDF)
• Appointment of Representative - Spanish (PDF)
• Appointment of Representative Form (PDF) 
• Appointments and Patient Recall (PDF)  
• Audiometer Form (PDF)
• Autoclave Maintenance and Run Log (PDF)

B

• Blood and Body Fluid Exposure Report Form (PDF)  
• Breast Cancer Treatment Information Sign (PDF)
• Bright Futures Promoting Oral Health (PDF)  

C

• Capitation Activity Analysis Report Field Descriptions (PDF) 
• Capitation Eligibility Summary Report by Group/Provider (BRM 11) (PDF)
• Capitation Remittance Remittance Detail Report (BRM 20) (PDF)
• Care Management Referral Form - Commercial Medicare and CMC (PDF) 
• CBAS Treatment Request Form (PDF) 
• Checklist for Safe Vaccine Storage and Handling (PDF) 
• Child Abuse Reporting (PDF) 
• Clean and Sanitary Environment (PDF)
• Clinical Payment Policy CP.MP.152 - Measurement of Serum 1 25-dihydroxyvitamin D (PDF) 
• Clinical Payment Policy CP.MP.153 - Helicobacter Pylori Serology Testing (PDF)
• Clinical Payment Policy CP.MP.154 - Thyroid Hormones and Insulin Testing in Pediatrics (PDF) 
• Clinical Payment Policy, CCP.MP.155 - EEG in the Evaluation of Headache (PDF) 
• Clinical Payment Policy CP.MP.156 - Cardiac Biomarker Testing for Acute Myocardial Infarction (PDF) 
• Clinical Payment Policy CP.MP.157 - 25-hydroxyvitamin D Testing in Children and Adolescents (PDF) 
• Clinical Payment Policy CP.MP.38 - Ultrasound in Pregnancy (PDF) 
• Clorox Regular Bleach (PDF)
• Confidential Morbidity Report (PDF) 
• Consent for Minors to Travel without an Escort (PDF)
• Controlled Substance Log Form (PDF)
• Criteria for Hospice Appropriateness (PDF)

D

• Decision Power Referral Fax Form (PDF) 
• Decontamination of Surface (PDF)  
• Delegation of Service Agreement Supervision of Physician Assistance (PDF)
• Delineation of UM Responsibilities (PDF)
• Dexa Scanner (PDF)
• Domestic Violence Reporting (PDF)

E

• Edinburgh Perinatal/Postnatal Depression Scale (EPDS) Questionnaire (PDF)
• Elder Abuse Reporting (PDF)
• Eligibility Report Field Descriptions (PDF) 
• Eligibility Summary by Group File (PDF)
• Eligibility Summary by Group and Provider Report Field Descriptions (PDF)
• Emergency Earthquake Plan (PDF)  
• Emergency Fire Plan (PDF)  
• Emergency Health Care Service (PDF)  
• Emergency Medication Dosage Chart (PDF)  
• Energency Protocol (PDF)  
• Emergency Response Worksheet (PDF)  
• Emergency Supplies Inventory Checklist (PDF)
• Endoscopy Matrix (PDF) 
• Equipment Calibration Log (PDF)
• Equiment Transfer Log for Sterilzation (PDF)
• ESRD Medical Evidence Report (PDF)

F

• Facility Site Review Guidelines (PDF) 
• Facility Site Review - Refrigerator & Freezer Temperature Log (PDF)
• Facility Site Review Tool (PDF)
• Facility Site Review Preaudit Checklist (PDF)
• Fire Safety and Prevention and emergency Non-Medical Procedures (PDF)
• Freezer Temperature Log for Vaccines (Celsius) (PDF) 
• Freezer Temperature Log for Vaccines (Fahrenheit) (PDF)  

G

• Government Programs Electronic Media Format Activity File (PDF)
• Government Programs Electronic Media Format Eligibility File (PDF) 
• Government Programs Electronic Media Format Member Status Table (PDF)
• Government Programs Electronic Media Format Remittance Detail File (PDF)

H

• Health Plan Interpreter Phone Numbers (PDF) 
• Hearing and Vision Graph (PDF)
• Hepatitis B Vaccination Declination (PDF)
• Hospice Consideration Request Letter (PDF) 
• Hospital Reinsurance Example (PDF)

I

• Identification card (Cal MediConnect) (PDF)
• Industry Collaboration Effort (ICE): Provider Tools to Care for Diverse Populations - CMC (PDF)
• Informed Consent and Human Sterilization Consent (PDF)
• Injectable Medication HCPCS/DOFR Crosswalk (PDF)
• Inpatient California Health Net Commercial Prior Authorization (PDF)
• Instrument Sterilization (PDF) 
• Interpreter Quality Standards Guidance and Requirements (PDF)  
• Interpreter Services (PDF)
• Interpreter Service Quick Reference Card (Cal Medi-Connect) (PDF) 
• Interpreter Service Quick Reference Card (CalViva) (PDF)
• Interpreters Available Poster (PDF)  

J

K

L

• Laboratory Services (PDF)
• Language Identification Postet (PDF)
• Language Proficiency Assessment Resources (PDF)
• Long-Term Care Authorization Notification Form PDF)

M

• Medical and Lab Equipment Maintenance (PDF) 
• Medical Assistance Certification (PDF) 
• Medical Assistance Training Letter (PDF) 
• Medical Assistance Venipuncture Certification (PDF) 
• Medical Records (PDF) 
• Medical Record - Adult Health Maintenance Checklist With Standards (PDF) 
• Medical Record - Advance Directive Labels (PDF) 
• Medical Record - Anticipatory Guidance Checklist (PDF) 
• Medical Record - Audiometric Screening (PDF) 
• Medical Record - Chronic Problem List (PDF)
• Medical Record - History (PDF)
• Medical Record - History Spanish (PDF)
• Medical Record - Language Labels (PDF)
• Medical Record - Medication and Chronic Problem Summary (PDF) 
• Medical Record - Message Log (PDF) 
• Medical Record - Preventive Care Forms - ages 0 - 50+ (PDF)
• Medical Record Review Tool (PDF) 
• Medical Record - Referral Log (PDF)
• Medical Record - Signature Page (PDF) 
• Medical Record - Test Results Labels (PDF) 
• Medical Waste Collection Tracking Log (PDF)  
• Medical Waste Log Sheet (PDF)  
• Medical/Behavioral Comanagement/Coordination of Care Form (PDF)
• Medicare and Medicare-Medicaid Plans Prescription Claim Form (PDF) 
• Medicare Capitation Activity Analysis Report (BRM 30) (PDF)
• Medicare Informational Letter to Patient and/or Provider/Physician (PDF) 
• Medicare Member Claim Form (PDF) 
• Medicare Provider Termination Notification Template (PDF) 
• Member Complaint Log (PDF)
• Minor's Rights to Sensitive Services (PDF)
• Monthly Equipment and Medication Replacement log (PDF)  
• Monthly Medication and Lab Supplies Inventory Checklist (PDF)

N

• Nondiscrimination Notice and Taglines (PDF) 
• Non-Physician Medical Practitioners (PDF)
• Notice of Action Letter Translations and Alternate Formats: Akorbi Plunet Portal Guide (PDF)
• Notice to Consumers (Physicians Assistance) (PDF) 
• Notice to Consumers (Physicians) (PDF)

O

• Office Cleaning Schedule (PDF)  
• Office Cleaning Log/Scheudle Year (PDF)
• Offshore Subcontracting Attestation: Participating Provider PDF)
• Oral Health Risk Assessment Tool (PDF)
• Outpatient California Health Net Commercial Prior Authorization (PDF)

P

• Payment Integrity Policy CC.PP.007 - Maximum Units of Service (PDF) 
• Payment Integrity Policy CC.PP.056 - Urine Specimen Validity Testing (PDF)
• Payment Integrity Policy CC.PP.063 - Place of Service Mismatch PDF) 
• Payment Integrity Policy CC.PP.501 30 day Readmission  (PDF) 
• Payment Integrity Policy HNCA.PP.053 - Leveling of Emergency Room Services (PDF)
• Pediatric Health Maintenance Checklist (PDF)
• Personnel and Staff Training (PDF)  
• Pharmaceutical Services (PDF)
• Physical Accessibility Review Survey (FSR Attachment C) (PDF)
• Physician Certification Statement Form - Request for Transportation (PDF) 
• Policy and Procedure: Appointments and Patient Recall Reference (PDF)
• Policy and Procedure: Bloodborne Pathogens and Waste Management (PDF)
• Policy and Procedure: Decontamination of Surfaces (PDF)
• Policy and Procedure: Emergency Health Care Services (PDF) 
• Policy and Procedure: Health Education (PDF) 
• Policy and Procedure: Individual Health Education Behavioral Assessment (IHEBA) (PDF)
• Policy and Procedure: Informed Consent and Human Sterilization Consent (PDF) 
• Policy and Procedure: Informed Consent and Minors' Rights (PDF)
• Policy and Procedure: Instrument Sterilization (PDF) 
• Policy and Procedure: Interpreter Services (PDF)
• Policy and Procedure: Personnel Training: Prior Authorization/Referrals (PDF)
• Policy and Procedure: Provision of Services 24 Hours a Day (PDF)
• Policy and Procedure: Referral and Consultative Services (PDF) 
• Policy and Procedure: Site Accessibility by Individuals with Physical Disabilities (PDF)
• Policy and Procedure: Staff Qualifications (PDF)
• Policy and Procedure: Standard and Universal Precautions(PDF)
• Policy and Procedure: Triage (PDF) 
• Potential Quality Issue Referral Form (PDF) 
• Preventive Services Screening and Equipment (PDF)
• Preventive Care Physican Examination Form - 1 month: and Under Infants (PDF) 
• Preventive Care Physican Examination Form - 1 - 2 months: Infants (PDF) 
• Preventive Care Physican Examination Form - 3 - 4 months: Infants (PDF) 
• Preventive Care Physican Examination Form - 5 - 6 months: Infants (PDF) 
• Preventive Care Physican Examination Form - 7 - 9 months: Infants (PDF) 
• Preventive Care Physican Examination Form - 10 - 11 months: Infants (PDF) 
• Preventive Care Physican Examination Form - 12 - 15 months: Toddlers (PDF) 
• Preventive Care Physican Examination Form - 16 - 23 months: Toddlers (PDF) 
• Preventive Care Physican Examination Form - 2 years: Children (PDF) 
• Preventive Care Physican Examination Form - 2 1/2 years (30 months): Children (PDF) 
• Preventive Care Physican Examination Form - 3 years: Children (PDF) 
• Preventive Care Physican Examination Form - 4 - 5 years: Children (PDF) 
• Preventive Care Physican Examination Form - 6 - 8 years: Children (PDF) 
• Preventive Care Physican Examination Form - 9 - 12 years: Children (PDF) 
• Preventive Care Physican Examination Form - 13 -16 years: Teens (PDF) 
• Preventive Care Physican Examination Form - 17 - 20 years: Teens (PDF) 
• Preventive Care Physican Examination Form - 21 - 39 years female: Adults (PDF) 
• Preventive Care Physican Examination Form - 21 - 39 years male: Adults (PDF) 
• Preventive Care Physican Examination Form - 40 - 49 years female: Adults (PDF) 
• Preventive Care Physican Examination Form - 40 - 49 years male: Adults (PDF) 
• Preventive Care Physican Examination Form - 50+ years female: Adults (PDF) 
• Preventive Care Physican Examination Form - 50+ years male: Adults (PDF) 
• Primary Care Services Eligible for Primary Care Incentive Payments in Calendar Year 2011 (PDF) 
• Primary Language Assessment Labels (PDF)
• Prior Authorization/Referrals (PDF)
• Prior Authorization Requirements (PDF) 
• Prostate Cancer Treatment Information Sign (PDF) 
• Provider CMC Marketing Material Checklist (PDF)
• Provider Dispute Resolution Request - Medicare (PDF)
• Provider Library Quick Reference Flyer (PDF)
• Provision of Service 24 Hours a day (PDF)

Q

Quick Reference Sheet (PDF)

R

• Radiology Health Branch Contact Info (PDF) 
• Radiology Services (PDF)
• Reconstructive Surgery Decision Tree (PDF)
• Referral Tracking Log (PDF)  
• Refrigerator Temperature Log for Vaccines (Celsius) (PDF) 
• Refrigerator Temperature Log for Vaccines (Fahrenheit) (PDF)
• Remittance Detail Report Field Descriptions (PDF)
• Reportable Diseases (PDF)
• Report of Suspected Dependent Adult/Elder Abuse Form and General Instructions (PDF)
• Respite Care Referral Form (PDF)

S

• Sample Site Evacuation Plan (PDF)
• SB 260 Reconciliation Report (BRM_28) (PDF) 
• SB 260 Reconciliation Report Format Exhibits I-II (PDF) 
• Shared-Risk Settlement Example (PDF)
• Sharps Injury Log (PDF)
• Site Accessibility by Individuals with Physical Disabilities (PDF) 
• Skin Cancer Screening Form (PDF) 
• Spill Kit Information (PDF)
• Staff Education Checklist (PDF) 
• Staff Qualifications (PDF) 
• Staff Signature Page Form for Member Medical Records (PDF) 
• Standard of Care Guidelines for Childhood Lead Screening (PDF)
• Standardized Procedures Requorements for Nurse Practitioners Practice (PDF) 
• Standardized and Universal Precautions (PDF)
• Staying Healthy Assessment (18 Years and Older) Arabic (PDF)
• Staying Healthy Assessment (18 Years and Older) English (PDF) 
• Staying Healthy Assessment (18 Years and Older) Farsi (PDF)
• Staying Healthy Assessment (18 Years and Older) Khmer (PDF) 
• Staying Healthy Assessment (18 Years and Older) Spanish (PDF)
• Staying Healthy Assessment (3-4 Years) English (PDF) 
• Staying Healthy Assessment (Senior) Arabic (PDF)
• Staying Healthy Assessment (Senior) English (PDF) 
• Staying Healthy Assessment (Senior) Farsi (PDF)
• Staying Healthy Assessment (Senior) Khmer (PDF)
• Staying Healthy Assessment (Senior) Spanish 
• Staying Healthy Assessment Policy (PDF)
• Supervising PA PAC Document (PDF)  
• Suspected Child Abuse Report (PDF) 
• Suspected Injury Report Form (PDF)

T

• TB Risk Assessment - English/Spanish (PDF)
• Triage (PDF)
• Transfer or Termination Incident Report (PDF)
• Transplant Request - BMT/PBSCT (PDF) 
• Transplant Request - Heart (PDF) 
• Transplant Request - Heart/Lung (PDF) 
• Transplant Request - Kidney (PDF) 
• Transplant Request - Kidney/Pancreas (PDF) 
• Transplant Request - Liver (PDF)
• Transplant Request - Lung (PDF)

U

• Ultra Clorox Germicidal Bleach (PDF) 
• Understanding Bleach (PDF) 
• Unlicensed Personnel (PDF)
• Urgent Request for Continuing Home Health Services (PDF) 
• Utilization Management Timeliness Standards - Medi-Cal (PDF) 
• Utilization Management Timeliness Standards - Medicare (PDF)

V

Vaccines for Children Program (PDF)

W

• Weekly Inpatient Denial Log Sheet (PDF)
• Women's Folic Acid (PDF)  
• Workplace Violence Protocol (PDF)

X

Y

Z