Forms and References
# | 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 - Chinese (PDF)
- After-Hours Sample Script - English (PDF)
- After-Hours Sample Script - Spanish (PDF)
- Applied Behavioral Analysis (ABA) Prior Authorization Request Form (PDF)
- Autism Spectrum Diagnosis (ASD) Confirmation of Diagnosis Form (PDF)
- Autoclave Log (PDF)
B
C
D
- 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)
E
F
G
H
I
- 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)
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)
N
O
P
- Palliative Care Providers (contracted)
- 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)
- Provider Notification of Pregnancy - Commercial (PDF)