Provider Forms

Provider Forms

Choose a form:

Advance Directives

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

Behavioral Health

• Diagnostic Evaluation Referral Form for BHT referrals – English
• Diagnostic Evaluation Referral Form for BHT referrals – Chinese
• Diagnostic Evaluation Referral Form for BHT referrals – Russian
• Diagnostic Evaluation Referral Form for BHT referrals – Spanish
• Diagnostic Evaluation Referral Form for BHT referrals – Tagalog
• Diagnostic Evaluation Referral Form for BHT referrals – Vietnamese
• PCP Referral Process Summary (for PCP Office Staff)
• PCP Flier
• Behavioral Health Treatment for Autism Flier
• PCP Referral to Carelon Form – English
• 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 – English
• Care Management Referral to Carelon Form – Chinese
• Care Management Referral to Carelon Form – Russian
• Care Management Referral to Carelon Form – Spanish
• Care Management Referral to Carelon Form – Tagalog
• Care Management Referral to Carelon Form – Vietnamese

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

Community Supports (CS)

• Housing Transition Navigation (HTN) Referral Form
• Medically Tailored Meals (MTM) Referral 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 Adult and Homeless Families Referral Form
• ECM Children and Youth 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