PDF Forms and References in Alphabetical Order
- Care Management Referral Form (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)s
- 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 Cold Sterilization Log (PDF)
- Confidential Morbidity Report (PDF)
- Decision Power Referral Fax Form (PDF)
- Diagnostic Evaluation/Assessment Form (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)
- ICD-10-CM Codes for Abortion-Related Services (PDF)
- Identification card (Elect Open Access) (PDF)
- Identification card (Ambetter PPO) (PDF)
- Identification card (PPO) (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)
- Inpatient California Health Net Commercial Prior Authorization (PDF)
- Interpreter Service Quick Reference Card (PDF)
- 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)
- 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)
- 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)
- Physical or Speech Therapy (PDF)
- Potential Quality Issue Referral Form (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)