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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.

New - Higher Level of Care (HLOC) Authorization Form

Higher Level of Care (HLOC) Authorization Form

New – Hospital/SNF Utilization Management Contact Information

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

Referral Form for Transportation Services and Physician Certification Statement

Behavioral Health Forms

Functional Behavioral Assessment/Progress Report

Case Management Forms

Care Management Referral Form

Disease Management Forms

CVD Referral Form

Health Education Forms

Health Education Referral Form

Medical Nutrition Therapy (MNT) 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

Interpreter Poster

Order the Interpreter Poster

Managed Long Term Services and Supports

CBAS Face to Face Assessment Request (CEDT) Form
MLTSS Referral Form
MTM Physician Order Form
Palliative Care Referral & Screening Tool

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 (Cal MediConnect) Coverage Determination Form
Prior Authorization Request Form – Medi-Cal

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

Provider Portal Resources

Provider Portal Reference Guide

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)