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Provider Forms

»  Treatment Authorization Request (TAR)
»  Pharmacy Authorization
»  Health Services
»  Member Services
»  Quality Programs
»  Claims


Treatment Authorization Request (TAR)

Outpatient TAR
Healthy Families TAR (50-1)
Healthy KidsTAR (50-1)
HealthWorx TAR (50-1)
CareAdvantageTAR (50-1)
San Mateo ACE TAR (50-1) 		Inpatient TAR
Healthy FamiliesTAR (18-1)
Healthy Kids TAR (18-1)
HealthWorx TAR (18-1)
CareAdvantage TAR (18-1)
San Mateo ACE TAR (18-1)

  Correction Form for TAR

Medi-Cal TAR
Call California Department of Health Services
1-800-541-5555

Pharmacy Authorization

  • Fax medication request forms to Pharmacy Services, 650-829-2045
  • Questions and information: 650-616-2088 Pharmacy Help Line
Medication Request Forms
   HPSM Medication Request Form
   Medicare Part D Request Form

   Synagis/RSV Authorization
Fax to HPSM 650-829-2045

   Formulary Modification Request
Fax to HPSM 650-829-2079

Health Services

Referral Authorizations
Non-urgent Fax: 650-829-2079
Urgent Fax: 650-829- 2021

  RA form for out-of-network providers
  Adminstrative Referral Authorization Form
  RA Form for the San Mateo ACE Program

Member Services

Fax: 650-616-8581

   Established Patients Only
HPSM contracted physicians need to complete this form to allow assignment of an HPSM member to their panel. Both provider and member signatures are required.

   Primary Care Physician Change Form
HPSM members who want to change their PCP can complete this form and fax to Member Services. Member signature is required.

Quality Programs

Staying Healthy Assessment Tools (SHAT)
   Instructions for Administration and Reimbursement

Forms for Parents
0 – 3 Years English Spanish Chinese Vietnamese Russian Hmong Lao
4 – 8 Years English Spanish Chinese Vietnamese Russian Hmong Lao
9 – 11 Years English Spanish Chinese Vietnamese Russian Hmong Lao

Forms for Teens and Young Adults
12 – 17 Years English Spanish Chinese Vietnamese Russian Hmong Lao
18+ Years English Spanish Chinese Vietnamese Russian Hmong Lao


Staying Healthy Tip Sheets - English
0 – 3 years 4 – 8 years 9 – 11 years 12 – 17 years 18+ years


Staying Healthy Tip Sheets - Español
0 – 3 años 4 - 8 años 9 - 11 años 12 - 17 años 18+ años


Claims
   CareAdvantage Waiver of Liability Statement
   Provider Dispute Resolution Request Form
   Supplemental Form for Multiple Claims



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