Download and print commonly requested forms for prior authorizations, coverage determination requests, referrals, screenings, enrollment for electronic claims submission and remittance advices, and more.
Administrative authorization request forms
- Applied Behavioral Analysis Referral Form (PDF, 399 KB)
- Community-Based Adult Services (CBAS) Inquiry (PDF, 266 KB)
- Community-Based Adult Services (CBAS) Treatment Authorization Request (PDF, 807 KB)
- Community Health Worker Benefit Extension Request Form (PDF, 519 KB)
- Community Health Worker Recommendation Form (PDF, 535 KB)
- DME Treatment Authorization Request (PDF, 201 KB)
- Healthcare Professional/Physician Administered Drug Requests (medical benefit drugs) (PDF, 67 KB)
- Home Health Treatment Authorization Request (PDF, 216 KB)
- Intermediate Care Facility – Developmentally Disabled Treatment Authorization Request (PDF, 327 KB)
- Long-Term Care Custodial Authorization Request – Room and Board (PDF, 528 KB)
- Non-Emergency Medical Transportation (NEMT) Physicians Certification Statement (PDF, 57 KB)
- Servicing Provider Change Request Form for Existing Authorization (PDF, 125 KB)
- Skilled Nursing Facility Service Authorization Request (PDF, 467 KB)
- Treatment Authorization Request for Medi-Cal Members (PDF, 859 KB)
Claims and payments forms and templates
- 10-Day Notice Fax Cover Sheet (PDF, 99 KB)
- 274+ Flat File Sample (XLSX, 31 KB)
- Billing Guide for ICF/DD Facilities Effective 2/1/24 (PDF, 162 KB)
- Billing Guide for LTC Facilities Effective 2/1/24 (PDF, 161 KB)
- Claims Fax Cover Sheet (PDF, 1 MB)
- SNF Claims Billing Guide DOS Prior to 2/1/24 (PDF, 323 KB)
Delegation oversight forms
- Compliance audit evidence grid (PDF, 313 KB)
- Delegation oversight newly contracted provider training attestation (PDF, 120 KB)
- Delegation oversight newly contracted provider training attestation – Specialty health plan/vendor (PDF, 121 KB)
- Disclosure of emerging claim deficiencies (PDF, 94 KB)
- Monthly timeliness report (Medi-Cal) (XLXS, 43 KB)
- Principal officer form – Claims primary and alternate (PDF, 113 KB)
- Principal officer form — Dual claims and PDR (PDF, 125 KB)
- Principal officer form — PDR primary and alternate (PDF, 124 KB)
- Provider dispute resolution report (Commercial and Medi-Cal) (XLXS, 32 KB)
Provider dispute forms
- Provider dispute resolution request (PDF, 159 KB)
- Provider dispute resolution request (multiple claims) spreadsheet (PDF, 116 KB)
Referral forms
- Community supports referral (PDF, 321 KB)
- Cultural and linguistically appropriate services referral (PDF, 1 MB)
- Health education referral (PDF, 113 KB)
- Maternity care referral (PDF, 231 KB)
- Medi-Cal Social Services and mental health referral form (PDF, 254 KB)
- Population Health Management/Case Management referral (PDF, 304 KB)
Reporting forms
- Blue Shield Promise PPC/HCAC submission form (PDF, 187 KB)
- Blue Shield Promise Potential Quality Issue Referral Form (PDF, 1.3 MB)
Other patient care forms
- Age-appropriate physical evaluation templates (PDF, 144 KB)
- Appointment of Representative, English (PDF, 150 KB)
- Appointment of Representative, Spanish (PDF, 335 KB)
- Clinical trial Medicaid attestation form (PDF, 135 KB)
- Critical incident report (PDF, 165 KB)
- Initial health appointment (IHA) Audit, Medi-Cal (PDF, 277 KB)
- Lead declination form, English (PDF, 136 KB)
- Lead declination form, Spanish (PDF, 122 KB)
- Medical assistant certificate (PDF, 122 KB)
- Palliative care patient eligibility screening tool (PDF, 271 KB)
- Palliative care recertification tool (PDF, 98 KB)
- Pregnancy notification form — Medi-Cal patients (PDF, 196 KB)
- Protocol for requesting interpretation services (PDF, 465 KB)
- Provider request for continuity of care (PDF, 1 MB)
- Request/Refusal for interpretive services (PDF, 69 KB)
- Request/Refusal for interpretive services (Spanish) (PDF, 68, KB)
- Request/Refusal for interpretive services (Threshold languages) (PDF, 991, KB)
Medical policy treatment authorization request forms
Find forms you may need to submit treatment authorization requests for Blue Shield Promise Medi-Cal members.
Prior authorization list
View the list of medical services and procedures requiring medical necessity review or supplemental documentation prior to payment.
Tips for submitting Medi-Cal claims
Learn about best practices for billing Medi-Cal claims.