Frequently Used Forms

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Claims
icon Provider Dispute Resolution Request Form 

Credentialing
icon CAQH Provider Data Portal
icon HIV and AIDS Specialist Form 
icon Provider Data Form
icon Supervising Physician Provider Verification Form

Prior Authorizations
icon Prior Authorization Code Look-up Tool
icon Prior Authorization 2025 Form
icon Prior Authorization 2024 Form


Additional Authorization Forms
icon Applied Behavior Analysis Referral Form
icon Behavioral Health Therapy Prior Authorization Form (Autism)
icon Community-Based Adult Services (CBAS) Request Form
icon Continuity of Care Form
icon DHCS 6013A Medical Review/Prolonged Care Assessment Form
icon HS-231 Certification for Special Treatment Program Services Form
icon Molina ICF/DD Authorization Request Form

Referral Forms
icon Care Management Referral Form
icon Community Health Worker Referral Form

Community Supports
icon CS Asthma Remediation Referral Form
icon CS Community Transition Services Referral Form
icon CS Day Habilitation Programs Referral Form
icon CS Environmental Accessibility Adaptations – Home Modification Physician Form
icon CS Environmental Accessibility Adaptations – Home Modification Referral Form
icon CS Housing Deposits Referral Form
icon CS Housing Tenancy and Sustaining Referral Form
icon CS Housing Transition Navigation Referral Form
icon CS Medically Tailored Meals Referral Form
icon CS Personal Care and Homemaker Services Referral Form
icon CS Recuperative Care Referral Form
icon CS Respite Services – Home Referral Form
icon CS Short-Term Post-Hospitalization Housing Referral Form
icon CS Transition to Assisted Living Facilities or Residential Care Facilities Referral Form

icon Dental Coordination Referral Form
icon Doula Services Referral Form
icon Enhanced Care Management Member Referral Form
icon Housing Specialist Referral Form
icon Pregnancy Referral Form

Transportation
icon Physician Certification Statement

Pharmacy
icon Medical Benefit (HCPCS/J-Code) Drug Prior Authorization Form
icon Prescription Drug Prior Authorization Request Form

Other Forms and Resources
icon ICE Roster Template
icon Provider Information Data Form

Medi-Cal Non-Covered Services
icon Member Grievance Form (English)
icon Member Grievance Form (Spanish)
icon Member Grievance Form (Arabic)
icon Member Grievance Form (Chinese)
icon Member Grievance Form (Hmong)
icon Member Grievance Form (Russian)
icon Member Grievance Form (Vietnamese)
icon Member Grievance Form (Tagalog)
icon Member Grievance Form (Farsi)
icon Allowed In-Office Lab Test List, effective 5-15-2018

Health Education Forms
icon Health Education Referral Form

Health Management Services Flyer (for Members only)
icon English | icon Spanish | icon Arabic | icon Vietnamese icon Chinese | icon Hmong | icon Armenian | icon Korean | icon Russian | icon Tagalog

icon Health Education Services Provider Resources Flyer (for Providers only)

Cultural & Linguistic Services Forms
Member Resources for Cultural and Linguistic Services (icon English | icon Spanish | icon Arabic)
Provider Resources for Cultural and Linguistic Services (icon English)

Smoking Cessation Resources
icon ACOG Guidelines – Smoking Cessation During Pregnancy
icon CA Quits Toolkit - A Guide to Integrate Tobacco Treatment into Health Systems
icon Support Groups and Classes

 

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