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Common Forms

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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 for 2014

A

Adult Transplant Notification Request Form

Annual OneCare (HMO SNP) Health Risk Assessment

Appeals and Grievance Form - OneCare (HMO SNP)

Appointment of Representative Form

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

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

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

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

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

Authorization for Use or Disclosure of Protected Health Information (PHI) to Family Member or Friend - English

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

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

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

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

Authorization Request Form (ARF)

Authorization Request Form (ARF) for Community-Based Adult Services (CBAS)

Authorization Request Form (ARF) for OneCare Connect

B

Benefit Inquiry for Community-Based Adult Services (CBAS)

C

CBAS Incident Reporting Form

CBAS Member Discharge Plan and Reason

Childhood Obesity / Health Education Request Form

Code of Conduct

Customized Wheelchair Evaluation Request

D

Diabetes Action Plan - English

Diabetes Action Plan - Spanish

Diabetes Action Plan - Vietnamese

E

End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration

H

Health Education / Disease Management Referral Form

I

IHSS Communication Form

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

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

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

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

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

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

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

L

Long-Term Care Treatment in Place Notification Form

M

Member Complaint Form - Medi-Cal

Member Complaint Form - Medi-Cal - Farsi

Member Complaint Form - Medi-Cal - Korean

Member Complaint Form - Medi-Cal - Spanish

Member Complaint Form - Medi-Cal - Vietnamese

Member Request to Amend Protected Health Information (PHI) - English

Member Request to Amend Protected Health Information (PHI) - Spanish

Member Request to Amend Protected Health Information PHI - Vietnamese

Member Request to Amend Protected Health Information PHI - Farsi

Member Request to Amend Protected Health Information PHI - Korean

Mental Health Level of Care Screening Tool

Multipurpose Senior Services Program (MSSP) - Referral

MSSP LTC/SNF Incident Reporting Form

N

Non-Emergency Medical Transportation (NEMT) Authorization Request

O

OC.CYS Inpatient Notification and Coordination Form

OC.CYS Mental Status Screening Form

P

Pregnancy Notification Report

Provider Dispute Resolution Request Form

Provider Complaint Resolution Form - Level II

R

Request for Accounting of Disclosures - English

Request for Accounting of Disclosures - Spanish

Request for Accounting of Disclosures - Vietnamese

Request for Accounting of Disclosures - Farsi

Request for Accounting of Disclosures - Korean

Request for Letter of Agreement

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

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

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

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

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

Restriction on Manner/Method of Confidential Communication - English

Restriction on Manner/Method of Confidential Communication - Spanish

Restriction on Manner/Method of Confidential Communication - Vietnamese

Restriction on Manner/Method of Confidential Communication - Farsi

Restriction on Manner/Method of Confidential Communication - Korean

Retro Authorization Request for Acute Inpatient Care

S

State Fair Hearing Form

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

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

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

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

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

Suspected Fraud or Abuse Referral Form - English

Suspected Fraud or Abuse Referral Form - Spanish

Suspected Fraud or Abuse Referral Form - Vietnamese

Suspected Fraud or Abuse Referral Form - Farsi

Suspected Fraud or Abuse Referral Form - Korean

UB04 Claims Form

W

Waiver of Liability Statement - OneCare (HMO SNP)

Wheelchair Clinical Questionnaire

Wheelchair Repairs Authorization Request

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