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Need to Find a Form or Glance at Guidelines?

Here's your one-stop shop for L.A. Care provider manuals and commonly used forms.

Manuals and Forms

Provider Manuals

To help you better understand our guidelines, policies and procedures, L.A Care issues a manual to its providers each year. You can review a PDF version by selecting the appropriate manual on the Resources links.

Provider Forms

Below are the most frequently requested forms for L.A. Care Providers. If you have a suggestion for how we can improve any of the available forms, please contact Provider Support.

Recently Added Forms

Higher Level of Care (HLOC) Authorization Form
Hospital UM Contact Information (Authorization Contact Cheat Sheet)
SNF UM Contact Information (Authorization Contact Cheat Sheet)

Utilization Management Forms

Prior Authorization Request Forms
Difficult Placement Authorization Request Form
Difficult Placement Authorization Request Form Checklist
Higher Level of Care (HLOC) Authorization Form
Hospital Priority & Type of Clinical Service Requested Fax Form
Hospital UM Contact Information (Authorization Contact Cheat Sheet)
SNF UM Contact Information (Authorization Contact Cheat Sheet)
SNF Authorization and Billing Guidance
Provider Authorization and Billing Reference Guide
Medi-Cal Shared Risk Amendment Template
Physician Certification Statement (PCS) form

Behavioral Health Forms

Functional Behavioral Assessment/Progress Report

Case Management Forms

Care Management Referral Form

Enhanced Care Management (ECM) Service Authorization Request (SAR) Form

Disease Management Forms

CVD Referral Form

Health Education Forms

Health Education Referral Form
Medical Nutrition Therapy (MNT) Referral Form
CS Medically Tailored Meals Referral Form

Claims Forms

CMS 1500 Claim Form
CMS 1500 Claim Form Instructions
Provider Dispute Resolution Request Form

Member Demographic Data Report

Member Demographic Data Report

Employee Language Skills Self-Assessment Form

Language Skills Self-Assessment Form

Initial Health Assessment Forms

Well Child Assessment Forms

Interpreter Poster

Order the Interpreter Poster

Managed Long Term Services and Supports

Caregiver Support Services: Service Authorization Request Form
CBAS Face to Face Assessment Request (CEDT) Form
MLTSS Referral Form
MTM Physician Order Form
Palliative Care Referral & Screening Tool
Environmental Accessibility Adaptations (EAA) Service Authorization Request (SAR) Form

Patient Interpreter Services Labels

Preferred Language Labels (Sized for Avery 5160)
Interpretation Request/Refusal Labels (Sized for Avery 5160)

Pharmacy & Formulary Forms

MedWatch Form
Ralphs Pharmacy Form
Ralphs Pharmacy Form (Spanish)

Prescription Drug Prior Authorization Request Forms

Medicare Plus (DSNP) Coverage Determination Form

Reference Guide

ELDA Technical Bulletin
Coding Reference Guide for Acute Respiratory Conditions
Provider Authorization and Billing Reference Guide
Medi-Cal Shared Risk Amendment Template
SNF Authorization and Billing Guidance
Hospital UM Related Fax Information for All L.A. Care Members
SNF Related Fax Information for All L.A. Care Members

Provider Portal Resources

Provider Portal Reference Guide

Social Services Forms

Homeless and Housing Support Services Program (HHSS) Form

Homeless and Housing Support Services Program (HHSS) Reauthorization Form

Housing Deposits Quick Reference Guide

Housing Deposits Services Request for Funds Form

L.A Care HHSS Community Supports Program Quick Reference Guide

L.A. Care Recuperative Care Community Supports Program Quick Reference Guide

Recuperative Care Prior Authorization Request Form

Request for Recuperative Care Extension Form

Additional Referral Forms

CA Pediatric WIC Referral Form
Critical Incident Report Form
Referral for Potential Quality of Care Issues Form

Provider Support

If you need assistance, please call:

1-866-LACARE6 (1-866-522-2736)