Provider Forms
For assistance with finding or submitting completed forms, contact Provider Services at 650-616-2106 or psinquiries@hpsm.org.
Authorization & Referral Forms
- ACE Referral Authorization Form
- Applied Behavioral Analysis Screening Form
- Behavioral Health Higher Level of Care Form - Adult
- Behavioral Health Higher Level of Care Form - Youth
- Behavioral Health Referral Form
- CareAdvantage Determination Request Form
- CareAdvantage Redetermination Request Form
- Community-Based Adult Services (CBAS) Referral Form
- Complex Case Management Referral Form
- Family Health Services Asthma Referral Form
- Formulary Modification Request Form
- Home Health Physician Referral Form
- Home Health Services - Retrospective Authorization Form
- HomeAdvantage FocusCare Checklist
- HomeAdvantage Member Referral Form
- Incontinence Supply Prescription Form
- NEMT Prior Authorization Form
- Palliative Care Referral: Adult
- Pediatric Case Management and Requests Form
- Prescription Drug Authorization Request Form
- Prior Authorization Request Form
- Referral Authorization Correction Form
Claims & Billing Forms
Clinical/Health Assessment Forms
- Applied Behavioral Analysis Screening Form
- Asthma Encounter Form - Adult
- Asthma Encounter Form - Pediatric
- Authorization for Life-Sustaining Treatment
- Behavioral Health Screening - Extended Form (Part B-D)
- Behavioral Health Screening - Initial Form (Part A)
- Behavioral Health Screening Scoresheet
Staying Healthy Assessment Tools
Dental Forms
Directory Information Change Form
Use this form to submit a change or verify that your information in HPSM's provider directory is correct.
Dispute Resolution Forms
- Provider Dispute Resolution Request Form
- CareAdvantage Provider Liability Waiver
- Provider Dispute Resolution Supplemental Form
Assignment & Un-assignment Forms
- CareAdvantage D-SNP Enrollment Form
- CareAdvantage EPO Provider Selection Form
- EPO Authorization Form
- Request for Reassignment as Provider
- Primary Care Provider Change Form
Quality Improvement Forms
- Accommodation Checklist For People With Disabilities
- In-person Interpreter Services Request Form
- Medical Record Review Survey
- Potential Quality Issue (PQI) Referral Form
- Preventable Conditions Reporting Form
- Site Review Survey
Please do not use the Prior Authorization Request Form for Pharmacy Drug Requests.