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
Claims
- Provider Dispute Resolution Form
- NPI Registration Form
- NPI Bulk Enumeration Form
- UB04 Form Sample
- CMS-1500 Form Sample
Community Health Worker (CHW)
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 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