Long Term Care 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 For Long Term Care

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 Long Term Care Department at 1-714-246-8444. We are here to help you.

A

Authorization Status Request (Sample)PDF File Indicator Image

C

CalOptima Direct Claims Instructions/Claims Resubmission FormPDF File Indicator Image

D

Deferral Extension Notification FormPDF File Indicator Image

Discharge Disposition FormPDF File Indicator Image

E

Electronic Funds Transfer Authorization Form (External Link to InstaMed Website)PDF File Indicator Image

F

Facility Navigation Form
(Please note that Form W-9 is also required with this form. Click on the link below to download it.)
Form W-9

H

Hospice Care Inpatient Information Sheet and InstructionsPDF File Indicator Image

Hospice Notification/Validation FormPDF File Indicator Image

I

ICF/DD, ICF/DD-H and ICF/DD-N Notification FormPDF File Indicator Image

L

Long Term Care Authorization Processing GuidelinesPDF File Indicator Image

Long Term Care Authorization Request FormPDF File Indicator Image

Long-Term Care Treatment in Place Notification FormPDF File Indicator Image

Long Term Services and Supports Assessments Request FormPDF File Indicator Image

N

Notification of Change of Address/Tax ID FormPDF File Indicator Image

Notification of Change of "Pay To" Address FormPDF File Indicator Image

Notification of Hospice Election/Revocation (Sample)PDF File Indicator Image

O

On-Site Visit/21-Day ListPDF File Indicator Image

P

Provider Complaint Form And InstructionsPDF File Indicator Image

Provider Dispute Resolution Request FormPDF File Indicator Image

Q

Quality Improvement Critical Incident and Abuse ReportPDF File Indicator Image

W

WebMD Enrollment FormPDF File Indicator Image

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