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

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

CalOptima Direct Claims Instructions/Claims Resubmission Form  Use this form for all claim inquiries and resubmissions.

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

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

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

Deferral Extension Notification Form  Use this form to request an extension or deferral of an authorization request.

Discharge Disposition Form  Use this form when discharging a CalOptima member from a long-term care facility.

Hospice Care Inpatient Information Sheet and Instructions  Use this form when transferring a Medi-Cal hospice patient to a general inpatient level of care.

Hospice Notification/Validation Form  Complete this form when requesting claim payment for hospice care.

ICF/DD, ICF/DD-H and ICF/DD-N Notification Form  Use this form to notify CalOptima when our members utilize intermediate-care facilities for the developmentally disabled (ICF/DD), habilitative (ICF/DD-H) and nursing (ICF/DD-N).

Long-Term Care Authorization Processing Guidelines  Learn the processing guidelines for long-term care authorizations.

Long-Term Care Authorization Request Form  Use this form to request long-term care authorization for our members.

Long-Term Services and Supports Assessments Request Form  Use this form -when requesting completed long-term services and supports assessments of CalOptima members.

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

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

Notification of Change of Address/Tax ID Form  Use this form when requesting a change of your address or tax identification number.

Notification of Change of "Pay To" Address Form  Use this form when requesting a change of your payment address.

On-Site Visit/21-Day List  This log tracks your on-site visit/21-day list for CalOptima members.

Provider Complaint Form And Instructions  Review instructions for filing a provider complaint.

Use this form when you are requesting a resolution to a provider dispute.

Use this form to alert CalOptima to any actual or alleged event or situation that creates risk or serious harm to the physical or mental health or safety of a CalOptima member.