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.


Behavioral Health

Holman Referral Form

To learn more about Behavioral Health click here


Pharmacy Forms and downloads


RBM Fact Sheet Quick Reference Guide 

To learn more about Radiology click here



For claims forms click here



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

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
Prior Authorization / Referral Process

Office Management
Medical Records
Provision of Services 24 hours
Appointments and Patient Recall
Referrals and Consultative Services
Staying Healthy Assessment Tools
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
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


Cultural & Linguistic

For more information click here


Fraud and Abuse Reporting for more info click here
Fraud by a Provider
Fraud by a Member (English) 
Fraud by a Member (Spanish)

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