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Frequently Used Forms

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

Claims
Provider Dispute Resolution Request Form

​Prior Authorizations
Service Request Form (Instructions)
Behavioral Health Prior Authorization Form
Behavioral Health Therapy Prior Authorization Form (Autism)
Q1 2017 PA Code Matrix
Q4 2016 PA Code Matrix
Q3 2016 PA Code Matrix
Q2 2016 PA Code Matrix
Q1 2016 PA Code Matrix
Q4 2015 PA Code Matrix
Continuity of Care Form
Prior Authorization 2016 Guide 

Referral Forms
Case Management Referral Form
Direct Referral Form
Behavioral Health Coordination of Care Form
Health Education Referral Form [MMG/Direct Providers | IPA Medical Group]

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

Verio Healthcare Provider Request Forms for DME Equipment and Supplies
Certificate of Medical Necessity/DME Order
Certificate of Medical Necessity – Oxygen
Certificate of Medical Necessity/Order – Pap
Incontinence Supply Order
Certificate of Medical Necessity-Enteral Nutrition

Other Forms and Resources
CCS Eligibility Guidelines Grid
Medi-Cal Non-Covered Services
Member Grievance Form (English)
Member Grievance Form (Spanish)
Pregnancy Notification Report Form
Pregnancy Notification Report Form – Los Angeles County
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

Contracted Providers Making Changes
Membership Panel Form
Provider Information Form

Credentialing

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

 

Health Education Forms

Health Management Services Flyer

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

 

Cultural & Linguistic Services Forms

Cultural and Linguistics Services Grid

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
ACOG Guidelines – Smoking Cessation During Pregnancy

 

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