Forms Library Welcome to the Forms Library. Contained below are links to most forms used by CenCal Health. Some forms may require providers to log in to the restricted section of the website to access. If you’re unable to find what you were looking for, please contact Provider Services at (805) 562-1676 or via email.
Authorizations Behavioral Health ADMHS Referral Form Behavioral Health and PCP Care Coordination Forms CenCal Care Coordination BH request from PCP CenCal Care Coordination PCP request from BH To learn more about Behavioral Health click here Pharmacy Pharmacy Forms and downloads Radiology RBM Fact Sheet Quick Reference Guide To learn more about Radiology click here Contracting/Credentialing California Participating Physician Application (CPPA) Addendum B Form Provider Information Form W-9 Taxpayer Information Notification of Practice Changes Form For more information about joining our network click here Claims For claims forms click here Facility Downloads Site Review Site Review Guidelines Medical Record Review Guidelines PARS Tool Attachment C Cidex Efficacy Glucometer Quality Control Hemacue Quality Control Hearing & Vision Screening Temperature Log Fahrenheit Temperature Log Celsius Medical Waste Mailback Sources Medical Waste Treatment Adult Immunization Record CDC Vaccine Abbreviations Vaccine Information Statements Facility Site Pre-Audit Checklist Sharps Injury Log Emergency Medication Dosage Chart Patient Referral Tracking Log Tuberculosis (TB) Risk Assessment - Adults Tuberculosis (TB) Risk Assessment - Children Posting for Doctor's Office Cidex Log Access Safety Site Access Clean and Sanitary Environment Emergency Non-Medical Medical and Lab Equipment Maintenance Emergency Health Care Services Personnel Staff Qualifications Non-Physician Medical Providers Unlicensed Personnel Staff Education Training (Revised) Child Abuse Reporting Form Child Abuse Reporting Instructions Elder Abuse Elder Abuse Report Domestic Violence Suspicious Injury Report Instructions Suspicious Injury Report Form Consents Prior Authorization / Referral Process Office Management Grievance Interpreter Medical Records Provision of Services 24 hours Appointments and Patient Recall Referrals and Consultative Services Staying Healthy Assessment Tools Triage Complaint Log Clinical Services Laboratory Services Pharmaceutical Services Radiology Services Preventive Services Health Education Screening and Equipment Infection Control Blood borne Pathogens & Waste Management Decontamination of Surfaces Universal Precaution Instrument Sterilization Sharps Injury Log Staff Training Bio hazardous Waste Handling Blood Borne Pathogens Exposure Prevention Child Abuse Domestic Violence Elder Abuse Emergency Earthquake Plan Emergency Fire Plan Emergency Medical Procedures Grievance Health Plan Referral Forms Health Plan Referral Infection Control Informed Consent Patient Confidentiality Sensitive Services Workplace Violence Protocol For information on Facility review click here Health Education For health materials click here Member Member Rights and Responsibilities - English Member Rights and Responsibilities - Spanish Member Grievance Form SBHI & SLOHI - English Member Grievance Form SBHI & SLOHI - Spanish Member Grievance Form HF,HK,PP2,IHSS - English Member Grievance Form HF,HK,PP2,IHSS - Spanish Resources for disabled and Special Needs Community Resources California Minor Consent Laws Cultural & Linguistic For more information click here Other Fraud and Abuse Reporting for more info click here Fraud by a Provider Fraud by a Member (English) Fraud by a Member (Spanish) Diabetes SMART Diabetes SMART Add/Remove Member Form Care Management Referral Form Preventive Healthcare For information please click here to view the provider manual Education and Training Materials click here Behavioral Health and PCP Care Coordination Forms CenCal Care Coordination BH request from PCP CenCal Care Coordination PCP request from BH