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
Claims
- Provider Dispute Resolution Form
- NPI Registration Form
- NPI Bulk Enumeration Form
- UB04 Form Sample
- CMS-1500 Form Sample
Community Health Worker (CHW)
Community Supports (CS)
- Community Supports Prior Approval Form
- Housing Transition Navigation (HTN) Referral Form
- Medically Tailored Meals/Groceries (MTM) Referral Form
- Housing Deposits Referral Form
- Housing Tenancy Sustaining Services Referral Form
- Home Modifications Referral Form
- Community Transitions (Nursing Facility Transition to Home) Referral Form
- Respite Services Referral Form
- Nursing Facility Transition/Diversion to Assisted Living Facilities Referral Form
Custodial Long-Term Care (LTC)
EDI
- SFHP Electronic Remittance Advice (ERA) Enrollment Form
- SFHP Electronic Fund Transfer (EFT) Authorization Agreement
Enhanced Care Management (ECM)
Facility Site Review
- FSR Checklist
- MRR Checklist
- PARS Checklist
- Interim Monitoring Form
- Evidence of Staff Training Log
- Evidence of Staff Training Log – Acupuncture
Member Grievance and Appeal
- Grievance English
- Grievance Spanish
- Grievance Chinese
- Grievance Vietnamese
- Grievance Russian
- Grievance Tagalog
- Grievance and Appeal Consent Form (English)
- Grievance and Appeal Consent Form (Spanish)
- Grievance and Appeal Consent Form (Chinese)
- Grievance and Appeal Consent Form (Vietnamese)
- Grievance and Appeal Consent Form (Russian)
- Grievance and Appeal Consent Form (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