Please complete the form, print it out and fax it to the number shown on the top of the form. This form must be approved by CenCal Health prior to the member receiving the requested item.
The Medical Request Form (MRF), must be printed out and faxed to CenCal Health by the prescriber for any pharmaceutical or medical supply that requires a Prior Authorization or is not on CenCal Health’s formulary.
Authorizations are not a guarantee of payment. The provider is responsible for verifying a member’s eligibility on the dates of service.
Please ensure patient’s eligibility is current prior to rendering service.