Provider Forms

Provider Forms

Choose a form:

Advance Directives

• Advance Health Care Directive – Russian
• Advance Health Care Directive – Chinese
• Advance Health Care Directive – Spanish
• Advance Health Care Directive – English
• Advance Health Care Directive – Vietnamese

Behavioral Health

• Diagnostic Evaluation Referral Form for BHT referrals(Use this form if there is a known diagnosis and/or problem behavior indicating BHT/ABA Referral)
• PCP Referral Process Summary (for PCP Office Staff)
• PCP Flyer
• Behavioral Health Treatment for Autism Flyer
• Behavioral Health Screening Form (Children 0 – 5)
• Behavioral Health Screening Form (Children 6 – 17)
• Behavioral Health Screening Form (Adult)
• PCP Referral to Carelon Form
• PCP Referral to Carelon Form (Chinese)
• PCP Referral to Carelon Form (Russian)
• PCP Referral to Carelon Form (Spanish)
• PCP Referral to Carelon Form (Vietnamese)
• Care Management Referral to Carelon Form

CBAS

• CBAS Referral Form
• CBAS Initiation and Prior Authorization Form

Claims

• Provider Dispute Resolution Form
• NPI Registration Form
• NPI Bulk Enumeration Form
• UB04 Form Sample
• CMS-1500 Form Sample

Community Health Worker (CHW)

• Recommendation Form

Custodial Long-Term Care (LTC)

• Initial Assessment Form
• Wound Assessment Form
• Wound Assessment Follow-Up
• LTC Prior Authorization

EDI

• SFHP Electronic Remittance Advice (ERA) Enrollment Form
• SFHP Electronic Fund Transfer (EFT) Authorization Agreement

Enhanced Care Management (ECM)

• ECM Referral Form

Facility Site Review

• FSR Checklist
• MRR Checklist
• PARS Checklist
• Interim Monitoring Form
• Evidence of Staff Training Log
• Evidence of Staff Training Log – Acupuncture

Member Appeals and Grievance

• Grievance_English
• Grievance_Spanish
• Grievance_Chinese
• Grievance_Vietnamese
• Grievance_Russian
• Grievance_Tagalog

Pain Management Patient Agreements and Informed Consent

• Chronic Pain Informed Consent – English
• Chronic Pain Patient-Provider Agreement – English
• Chronic Pain Informed Consent – Spanish
• Chronic Pain Patient-Provider Agreement – Spanish
• Chronic Pain Informed Consent – Chinese
• Chronic Pain Patient-Provider Agreement – Chinese
• SFHP Patient Care Agreement

Pharmacy

• Prescription Drug Prior Authorization Request Form for Healthy Workers HMO
• Formulary Modification Form for Healthy Workers HMO

Prior Authorization

• Prior-Authorization Request Form
• Non-Emergent Medical Transportation (NEMT) Combination Physician Certification and Prior Authorization Form