Provider Forms

For assistance with finding or submitting completed forms, contact Provider Services at 650-616-2106 or psinquiries@hpsm.org.

Authorization & Referral Forms

Prior Authorization Request Form

Jun 1, 2018, 18:13 PM by Rich Brenner
Download (pdf) 1108 KB

Claims & Billing Forms

Prior Authorization Request Form

Jun 1, 2018, 18:13 PM by Rich Brenner
Download (pdf) 1108 KB

Clinical/Health Assessment Forms

Prior Authorization Request Form

Jun 1, 2018, 18:13 PM by Rich Brenner
Download (pdf) 1108 KB

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

Prior Authorization Request Form

Jun 1, 2018, 18:13 PM by Rich Brenner
Download (pdf) 1108 KB

Assignment & Un-assignment Forms

Prior Authorization Request Form

Jun 1, 2018, 18:13 PM by Rich Brenner
Download (pdf) 1108 KB

Quality Improvement Forms

Prior Authorization Request Form

Jun 1, 2018, 18:13 PM by Rich Brenner
Download (pdf) 1108 KB

Please do not use the Prior Authorization Request Form for Pharmacy Drug Requests.