Common Forms

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Common Forms

Questions? If you have questions or need assistance, call our Provider Relations Department at 1-714-246-8600, Monday through Friday from 8 a.m. to 4 p.m. Pacific Time.

Find Common Forms

We want to make it easy for you to find the forms you need. If you don't see the form you are looking for, or if you aren't sure which one you need, please call our Provider Relations Department at the number on the right side of the screen. We are here to help you.

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1500 Health Insurance Claims Form

A

Accounting of Disclosures - Medi-Cal

Accounting of Disclosures - Healthy Families Program

Accounting of Disclosures - OneCare (HMO SNP)

Amend Protected Health Information (PHI) - Medi-Cal

Amend Protected Health Information (PHI) - Healthy Families Program

Amend Protected Health Information (PHI) - OneCare (HMO SNP)

Appeals and Grievance Form - OneCare (HMO SNP)

Appointment of Representative

Asthma Health Program Form

Authorization for Use or Disclosure of Protected Health Information (PHI) - Medi-Cal

Authorization for Use or Disclosure of Protected Health Information (PHI) - Healthy Families Program

Authorization for Use or Disclosure of Protected Health Information (PHI) - OneCare (HMO SNP)

Authorization for Use or Disclosure of Protected Health Information (PHI) to Family Member or Friend Involved in Care - Medi-Cal

Authorization Request Form (ARF)

C

California Participating Physician Application

CalOptima Care Network Primary Care Provider Selection Form

Childhood Obesity / Health Education Request Form

California Participating Physician Application - Addendum F

California Participating Physician Reapplication

Code of Conduct

Customized Wheelchair Evaluation Request

D

Diabetes Health Program Form - Medi-Cal

Diabetes Health Program Waiver Form - OneCare (HMO SNP)

Disease Management Referral Form

E

Electronic Funds Transfer (EFT) Authorization and Instructions

H

Health Education / COPTP Referral Form

Health Risk Questionnaire - Healthy Families Program

Heart Health Program Waiver Form - OneCare (HMO SNP)

I

Individual Request for Access to Protected Health Information (PHI) - Medi-Cal

Individual Request for Access to Protected Health Information (PHI) - Healthy Families Program

Individual Request for Access to Protected Health Information (PHI) - OneCare (HMO SNP)

Initial OneCare (HMO SNP) Health Risk Assessment

Intake Form - Multipurpose Senior Services Program (MSSP)

M

Member Complaint Form - Medi-Cal

Member Complaint Form - Medi-Cal - Farsi

Member Complaint Form - Healthy Families Program

Member Request to Amend Protected Health Information (PHI) - Medi-Cal

Member Request to Amend Protected Health Information (PHI) - Healthy Families Program

Member Request to Amend Protected Health Information PHI - OneCare (HMO SNP)

N

Non-Emergency Medical Transportation (NEMT) Authorization Request

O

OC.CYS Healthy Families Program Mental Health Response Form

OC.CYS Healthy Families Program Referral Form

OC.CYS Inpatient Notification and Coordination Form

OC.CYS Mental Status Screening Form

OneCare New Member Orientation Invitation

P

Pregnancy Notification Report

Provider Dispute Resolution Form

Provider Dispute Resolution Form - Level II

R

Request for Accounting of Disclosures - Medi-Cal

Request for Accounting of Disclosures - Healthy Families Program

Request for Accounting of Disclosures - OneCare (HMO SNP)

Request for Restriction on Use or Disclosure of Protected Health Information (PHI) - Medi-Cal

Request for Restriction on Use or Disclosure of Protected Health Information (PHI) - Healthy Families Program

Request for Restriction on Use or Disclosure of Protected Health Information (PHI) - OneCare (HMO SNP)

Restriction on Manner/Method of Confidential Communication - Medi-Cal

Restriction on Manner/Method of Confidential Communication - Healthy Families Program

Restriction on Manner/Method of Confidential Communication - OneCare (HMO SNP)

Retro Authorization Request for Acute Inpatient Care

S

Screenings for CalOptima Member - Healthy Families Program

Security and Privacy Breach Incident Report - Healthy Families Program

State Fair Hearing Form

Staying Healthy Assessment - Medi-Cal

Statement of Disagreement Request to Include Amendment Request and Denial with Future Disclosures - Medi-Cal

Statement of Disagreement Request to Include Amendment Request and Denial with Future Disclosures - Healthy Families Program

Statement of Disagreement Request to Include Amendment Request and Denial with Future Disclosures - OneCare (HMO SNP)

Suspected Fraud or Abuse Referral Form

UB04 Claims Form

W

Waiver of Liability Statement - OneCare (HMO SNP)

Wheelchair Clinical Questionnaire

Wheelchair Repairs Authorization Request

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