Common Forms

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  Standard claim form used when billing for services provided to our members.

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

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

Anticipatory Guidance and Blood Lead Refusal Form  Documents anticipatory guidance and parent/guardian refusal of blood lead screening for child members.

Appointment of Representative Form  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)  Gives permission for the release of member health information.

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

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

Behavioral Health–Authorization Request Form (BH-ARF)  Submit along with clinical documentation to request a review to authorize behavioral health services. For Applied Behavior Analysis (ABA), please use the BHT-ARF form.

Behavioral Health Treatment-Authorization Request Form (BHT-ARF)  Submit along with clinical documentation to request a review to authorize BHT/ABA service.

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

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.

Childhood Lead Poisoning Prevention Branch Provider Attestation  Use this form to attest to following the Childhood Lead Poisoning Prevention Branch guidelines when conducting blood lead screening tests.

View CalOptima Health’s commitment to conducting activities and operations in compliance with applicable law.

Forms outline the preventive health services that need to be addressed and documented at each child member’s periodic health assessment (well-child visit). These forms are a resource to support providers with the provision of pediatric preventive services. Pediatric Preventive Services are provided to members under 21 years of age in accordance with current American Academy of Pediatrics (AAP) bright future and U.S. Preventive Task Force (USPSTF) recommendations. These forms are not audit tools and use is not required.

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

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

End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration  Complete for all ESRD patients.

Health and Wellness Referral Form  Complete form to refer members to CalOptima Health's health management programs.

Health Homes Program Referral Form  Use this form to refer members to CalOptima Health's Health Homes Program.

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

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

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

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

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

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

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

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.

Offset Consent Form Use this form when requesting CalOptima to offset overpaid amounts against future claims payments in lieu of submitting a check.

OneCare Health Risk Assessment Form Fill out this form to identify health care needs and help our members stay healthy.

Overpayment Form Use this form when submitting checks in response to a CalOptima notice of overpayment.

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

Submit when disputing a level-one member complaint.

Submit when disputing a level-II member complaint.

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

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

Request for Restriction on Use or Disclosure of Protected Health Information (PHI)   Submit with requesting release of limited PHI inform.

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

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

State Fair Hearing Form  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  Submit when rebutting denial by CalOptima to change member’s Protected Health Information (PHI).

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

Transplant Notification and Request Form  Use this form for all transplant services, including pre-transplant evaluations.

Transportation of a Minor Consent Form  Submit when granting permission for minor dependent to be transported by CalOptima Health’s Non-Medical Transportation (NMT) or Non-Emergency Medical Transportation (NEMT) service providers.

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

Waiver of Liability Statement  Submit when waiving right to collect payment from a OneCare or OneCare Connect member.

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

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