Manuals, Forms and Resources
Important Update
Starting January 1, 2024, California Health & Wellness Plan will no longer serve Medi-Cal members. The information and resources provided on this webpage are applicable to services rendered on or before December 31, 2023.
If you are a provider in Amador, Calaveras, Imperial, Inyo, Mono, or Tuolumne counties, who is part of the Health Net provider network starting January 1, 2024, please visit Health Net for services rendered on or after January 1, 2024.
Forms
- Endoscopy Matrix – English (PDF)
- Potential Quality Issue (PQI) Referral Form – English (PDF)
- Prescription Drug Prior Authorization or Step Therapy Exception Request Form (No. 61-211) – English (PDF)
- Prior Authorization Form – Inpatient – English (PDF)
- Prior Authorization Form – Outpatient – English (PDF)
- Provider Dispute Resolution Request Form – English (PDF)