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)
• 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

Bariatric Surgery Performance Centers (PDF)

C

• 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) 
• Confidential Morbidity Report (PDF)

D

• Decision Power Referral Fax Form - Commercial and Medicare (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)
• Eligibility Report Field Descriptions (PDF)

F

G

H

Hepatitis B Vaccination Declination (PDF) 

I

• ICD-10-CM Codes for Abortion-Related Services (PDF)
• Identification card (Large group PureCare HSP) (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)
• Inpatient California Health Net Commercial Prior Authorization (PDF)
• Interpreter Service Quick Reference Card (PDF)

J

K

L

Language Identification Poster (PDF)

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

• NICU Level of Care Criteria (PDF) 
• Nondiscrimination Notice and Taglines (PDF)

O

• Offshore Subcontracting Attestation: Participating Provider (PDF) 
• Order of Benefits for Dependent Children (PDF) 
• Out-of-Pocket Maximum - Back (PDF)
• Out-of-Pocket Maximum - Front (PDF)
• Out-of-Pocket Maximum Copayment Example (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.068 Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF) 
• Payment Integrity Policy CC.PP.069 Multiple Procedure Reduction: Ophthalmology (PDF)  
• Payment Integrity Policy CC.PP.501 30 day Readmission (PDF) 
• Payment Integrity Policy HNCA.PP.053 - Leveling of Emergency Room Services (PDF)
• Physical or Speech Therapy (PDF) 
• Potential Quality Issue Referral Form (PDF) 
• Prescription Drug Prior Authorization or Step Therapy Exception Form (PDF) 
• Provider Dispute Resolution Request - Commercial and Medi-Cal (PDF) 
• Provider Dispute Resolution Request - IFP (PDF)

Q

Quick Reference Guide (PDF)

R

• Reportable Diseases (PDF) 
• Request for Confidential Communication Form (PDF) 

S

• Sample - Hospital Refusal Letter (PDF)
• Subscriber OOPM Notification Letter (PDF)

T

Transplant Performance Centers (PDF)

U

• Urgent Request for Continuing Home Health Services (PDF)
• Urgent Request for Continuing Occupational, Physical or Speech Therapy (PDF)

V

Verifying Eligibility (IFP) (PDF)

W

X

Y

Z