Resources

Common Forms

Top forms and documents for providers

If you do not see a form you are looking for, or you have any questions, please call our Provider Relations department at 714-246-8600.

1500 Health Insurance Claims Form for 2014 Download PDF Icon Standard claim form used when billing for services provided to our members.

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Add, Change, and Termination Form Download PDF Icon This form must be completed to report any additions, changes, and/or terminations to a provider’s network affiliates.

Add, Change, and Termination Form User Guide Download PDF Icon Use this guide to assist you in completing a request to report any additions, changes or terminations to a provider's network affiliate.

Adult Transplant Notification Request Form Download PDF Icon Use this form for all transplant services, including pre-transplant evaluations (children under the age of 21 refer to CCS).

Annual OneCare (HMO SNP) health risk assessment Download PDF Icon Fill out this form to identify health care needs and help our members stay healthy.

Appeals and Complaint Form — OneCare (HMO SNP) Download PDF Icon Use this form to request a coverage decision, appeal, or to file a formal complaint for any part of care or service from OneCare.

Appointment of Representative Form Download PDF Icon Used when appointing an individual to act as a representative of our member in connection to claim.

Authorization for Use or Disclosure of Protected Health Information (PHI) Download PDF Icon Gives permission for the release of member health information.

Authorization for Use or Disclosure of Protected Health Information (PHI) to Family Member or Friend  Download PDF Icon Gives permission for the release of member health information to a member’s family or friend.

Authorization Request Form (ARF) Download PDF Icon Submit along with clinical documentation to request a review to authorize member’s treatment plan.

Authorization Request Form (ARF) for OneCare Connect Download PDF Icon Submit along with clinical documentation to request a review to authorize OneCare Connect member’s treatment plan.

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Behavioral Health–Authorization Request Form (BH-ARF) Download PDF Icon This form is required to request authorization for applied behavioral analysis (ABA) and psychological testing

Benefit Inquiry for Community-Based Adult Services (CBAS) Download PDF Icon Submit form for benefit information of CBAS participants.

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Community-Based Adult Services (CBAS) Authorization Request Form (ARF) Download PDF Icon Submit along with clinical documentation to request a review to authorize CBAS participant’s treatment plan.

CBAS Incident Report Form Download PDF Icon Used to provide a summary of adverse events that occur at or in transit to a CBAS center.

CBAS Member Discharge Plan and Reason Download PDF Icon Complete form to provide reason for CBAS discharge of member and continued treatment plan.

Childhood Obesity / Health Education Request Form Download PDF Icon Complete form to request health education and materials for members.

Code of Conduct Download PDF Icon View CalOptima’s commitment to conducting activities and operations in compliance with applicable law.

Customized Wheelchair Evaluation Request Download PDF Icon Submit to evaluate and request member need for wheelchair equipment.

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Diabetes Action Plan Download PDF Icon Complete and review with member for ongoing monitoring and treatment of diabetes.

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Health Education / Disease Management Referral Form Download PDF Icon Complete form to refer members to CalOptima’s health management programs.

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In-Home Supportive Services (IHSS) Communication Form Download PDF Icon Submit this form to update information regarding IHSS.

Individual Request for Access to Protected Health Information (PHI) Download PDF Icon Submit this form to update information regarding IHSS.

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Long-Term Care Treatment in Place Notification Form Download PDF Icon Submit when requesting to provide services at LTC facility.

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Member Complaint Form — Medi-Cal Download PDF Icon Submitted by a member to inform CalOptima of a grievance or appeal.

Member Request to Amend Protected Health Information Download PDF Icon Submit when member wants to change information in health record.

Mental Health Level of Care Screening Tool Download PDF Icon Complete when evaluating member for behavioral health services.

Multipurpose Senior Services Program (MSSP) — Referral Download PDF Icon Complete with evaluating and referring member for MSSP services.

MSSP LTC/SNF Incident Reporting Form Download PDF Icon Submit when notifying CalOptima of a critical incident involving member.

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Non-Emergency Medical Transportation (NEMT) Authorization Request Download PDF Icon Complete when evaluating and requesting member’s need for NEMT.

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OC CYS Inpatient Notification and Coordination Form Submit when notifying Orange County Health Care Agency/Behavioral Health (HCA/BH), Children & Youth Services (CYS) of inpatient admission of any child who is either suspected of or who is determined to be seriously emotionally disturbed (SED).

OC CYS Mental Status Screening Form Complete when evaluating the mental status of members.

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Pregnancy Notification Report Download PDF Icon Complete to provide CalOptima with risk assessment of members who are expecting mothers.

Provider Dispute Resolution Request Form Download PDF Icon Submit when disputing a level-one member complaint.

Provider Complaint Resolution Form — Level II Download PDF Icon Submit when disputing a level-II member complaint.

Psychological Testing Pre-Authorization Request Form Download PDF Icon You must submit this form to pre-authorize all psychological testing

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Request for Accounting of Disclosures  Download PDF Icon Submit to receive a record of how member PHI was released.

Request for Letter of Agreement Download PDF Icon Submit when requesting a letter of agreement from CalOptima.

Restriction on Manner/Method of Confidential Communication Form  Download PDF Icon Request to receive confidential communications of PHI by different ways or to a different address.

Retro Authorization Request for Acute Inpatient Care Download PDF Icon Submit when requesting acute inpatient care services for member retroactively.

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State Fair Hearing Form Download PDF Icon Submit when requesting a State Hearing to dispute a decision about a member’s health care.

Statement of Disagreement Request to Include Amendment Request and Denial with Future Disclosures Download PDF Icon Submit when rebutting denial by CalOptima to change member’s Protected Health Information (PHI).

Suspected Fraud or Abuse Referral Form  Download PDF Icon Submit to request investigation of suspected fraud or abuse.

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UB04 claims form Download PDF Icon Standard claim form that any institutional provider can use for the billing of medical and mental health claims.

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Waiver of Liability Statement — OneCare (HMO SNP) Download PDF Icon Submit when waiving right to collect payment from OneCare member.

Wheelchair Clinical Questionnaire Download PDF Icon Complete when evaluating member’s need for new seating equipment (wheelchair).

Wheelchair Repairs Authorization Request Download PDF Icon Complete when requesting repairs or services to member’s wheelchair.

Contact Us
  • Providers and other health care professionals with questions regarding Medi-Cal, OneCare Connect, OneCare or PACE can call the Provider Relations department at 714-246-8600 or email: providerservices@caloptima.org

Electronic Data Interchange (EDI)
Provider Disputes
  • Dispute Process
    Review the payment dispute process for Medi-Cal and OneCare contracted providers

Prior Authorizations

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