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Frequently Used Forms

Please click on a form below to view a PDF printable version.

The files below are in PDF format (pdf icon)

Medication Prior Authorization Request Form12/14
CCS Eligibility Guidelines Grid 
Member Grievance Form (English) 04/09            
Member Grievance Form (Spanish) 04/09
Coordination of Care Form 02/14
Continuity of Care Form
Behavioral Health Prior Authorization Form
Service Request Form (Instructions) 09/09
Service Request Form 10/12
Direct Referral Form 03/10
Prior Authorization 2012 Guide 04/12
Prior Authorization 2013 Guide 04/13
Prior Authorization 2014 Guide 01/14
Prior Authorization 2015 Guide 01/15
Prior Authorization Codification 2013
Prior Authorization Codification 2014 10/14
Q3 2015 Prior Authorization Codification
Pregnancy Notification Report Form 01/14
Health Education Referral Form [MMG/Direct Providers | IPA Medical Group]
Medi-Cal Non-Covered Services
Enhanced Body Mass Index-For-Age Percentile Growth Charts and BMI Measurement - Boys
Enhanced Body Mass Index-For-Age Percentile Growth Charts and BMI Measurement - Girls
Adult Body Mass Index Table
Provider Dispute Resolution Request Form

 

Credentialing

CA Participating Provider Application(CPPA)
CPPA Addendum A 
CPPA Addendum B

 

Materials Order Forms

HE Print Materials List
Weight Management Print Materials List
How to Order Tools for Developmental Checkups for California's Kids

 

Cultural & Linguistic Services Forms

Employee Language Skills Self-Assessment Form

Staying Healthy Assessment Requirement

This requirement applies to all managed Medi-Cal members.

The initial health assessment includes the Initial Health Education Behavioral Assessment (IHEBA) which utilizes the “Staying Healthy Assessment”(SHA) form. The SHA forms are produced by DHCS and consist of 9 specific age categories (0-6 months, 7-12 months, 1-2 years, 3-4 years, 5-8 years, 9-11 years, 12-17 years, adult and seniors).

The assessment is designed to be completed by members age 12 and over and by parents for ages 11 and under, while waiting for their medical visit. If a member or parent requests help with completion, it must be provided. This assessment is designed to initiate dialogue between member and provider facilitating focused health education counseling addressing health behavior change.

This assessment must be completed with all new members within 120 days of enrollment into the plan. It must also be done with all existing patients at their next non-acute care visit and when entering into a new age category.

Staying Healthy Assessment Resources

  • Click here to view the Staying Healthy Assessment Provider Training video
  • Click here for the Staying Healthy Assessment Training Attestation Sign-in Form

Staying Healthy Assessment Forms (pdf icon)

See links below for Staying Healthy Assessment forms in English, Spanish, Arabic, Farsi, Khmer, Somali, Armenian, Chinese, Hmong, Korean, Russian, Tagalog and Vietnamese

 

If you are unable to access the forms please contact your Provider Services representative.

Alternative Forms or Electronic Formats

If you are planning to use an alternative to the SHA forms and/or converting the SHA forms into an electronic format, please complete the request form below and submit it to Molina at least one month before using the alternative form(s).

SHA Electronic or Other Format Notification Form

Use of Bright Futures Notification Form

Alternative IHEBA Notification Form


Smoking Cessation Resources

Support Groups and Classes

 

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