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
#
A
- AAP Recommendations for the Preventive Pediatric Health Care (PDF)
- Activity Analysis Report (PDF)
- Activity Analysis Report Field Descriptions (PDF)
- Adult AIDS/HIV Confidential Case Report (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)
- Autoclave Log (PDF)
B
C
- Care Management Referral Form - Commercial Medicare (PDF)
- CCS Program Application (PDF)
- Certification for Contracts Grants, loans, and Cooperative Agreements (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)
- Cold Sterilization Log (PDF)
- Commercial Electronic Media Format - Expanded Eligibility File ACE 42 (PDF)
- Commercial Informational Letter to Member or Provider (Carve-out Situations) (PDF)
- Confidential Morbidity Report (PDF)
- Criteria for Hospice Appropriateness (PDF)
D
- Decision Power Referral Fax Form - Commercial and Medicare (PDF)
- Diagnostic Procedures Requiring Prior Authorization for Health Net of California (PDF)
- Directory Removal for At-Risk Providers Form (PDF)
- Disclosure of Lobbying Activities Form and Disclosure Form Instructions (PDF)
- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Coding Policies (PDF)
E
- Edinburgh Perinatal/Postnatal Depression Scale (EPDS) Questionnaire (PDF)
- Electronic Media Format Activity File (PDF)
- Electronic Media Format Eligibility Summary by Group File (PDF)
- Electronic Media Format Remittance Detail File (PDF)
- Eligibility Report (BRM 42I) (PDF)
- Eligibility Report (BRM 42P) - Professional (PDF)
- Eligibility Report Field Descriptions (PDF)
- Eligibility Summary by Group Report (BRM 13B) (PDF)
- Eligibility Summary By Group Report Field Descriptions (PDF)
- Eligibility Summary by Group/Provider Report (PDF)
- Endoscopy Matrix (PDF)
F
G
H
I
- ICD-10-CM Codes for Abortion-Related Services (PDF)
- Identification card (Elect Open Access) (PDF)
- Identification card (HMO) (PDF)
- Identification card (Ambetter HMO) (PDF)
- Identification card (Select POS) (PDF)
- Individual Family Plan member eligibility status displayed on the secure provider portal (PDF)
- Industry Collaboration Effort (ICE): Provider Tools to Care for Diverse Populations (PDF)
- Injectable Medication HCPCS/DOFR Crosswalk (PDF)
- Inpatient California Health Net Commercial Prior Authorization (PDF)
- Interpreter Service Quick Reference Card (PDF)
J
K
L
M
- Medical Record - Adult Health Maintenance Checklist With Standards (PDF)
- Medical Record - Advance Directive Labels (PDF)
- Medical Record - Audiometric Screening (PDF)
- Medical Record - History Spanish (PDF)
- Medical Record - Medication and Chronic Problem Summary (PDF)
- Medical Record - Signature Page (PDF)
- Medical-Behavioral Comanagement-Coordination of Care Form (PDF)
- Member Grievance Form (PDF)
N
O
P
- Palliative Care Providers (contracted)
- Physical or Speech Therapy (PDF)
- Potential Quality Issue Referral Form (PDF)
- PPG Professional Batch Form (PDF)
- PPG OOPM Notification Letter - Hospitalization (PDF)
- Prescription Drug Prior Authorization or Step Therapy Exception Form (PDF)
- Prostate Cancer Treatment Information Sign (PDF)
- Provider Dispute Resolution Request - Commercial and Medi-Cal (PDF)
- Provider Dispute Resolution Request - IFP (PDF)
Q
R
S
T
- 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)
- Transplant Performance Centers (PDF)
- Transplant Review Process Phase I - Internal Review (PDF)
- Transplant Review Process Phase II - External Review (PDF)
- Type 1-APTC Pend Claim Letter (PDF)
- Type 3A-APTC Primary Care Physicians (PCP)/PPG Letter (PDF)
- Type 3B-APTC Claims Look-Back Letter (PDF)
- Type 4-APTC Authorization Rescind Letter (PDF)
- Type 5-APTC Inpatient Authorization Rescind Letter (PDF)