Resources
- Provider Education
- Initial Health Assessment Forms
- Staying Healthy Forms
- Member Grievance Forms and Links
- Documentation Tools for Success
- Reference Links
- Policies and Procedures
- AB 1455
- Provider Dispute Resolution Request
- Other Forms
Provider Education
- California Children’s Services (CCS)
- Child Health and Disability Prevention Program
- Comprehensive Perinatal Program
- Staying Healty Assessment Individual
Initial Health Assessment Forms
ADULT
BABY
CHILD
Staying Healthy Forms
English
Spanish
Vietnamese
Member Grievance Forms and Links
- Aetna Grievance Form English
- Aetna Grievance Form Spanish
- Blue Cross Grievance Form English
- Blue Cross Grievance Form Chinese
- Blue Cross Grievance Form Korean
- Blue Cross Grievance Form Spanish
- Blue Cross Grievance Form Tagalog
- Blue Cross Grievance Form Vietnamese
- Blue Shield Grievance Form English
- Cigna Grievance Form English
- Health Net Grievance Form Spanish
- UnitedHealthcare Member Grievance Forms can be obtained in the following ways:
- Log onto the UnitedHealthcare Member Portal at www.UnitedHealthcare.com
- Log onto the UnitedHealthcare Member Portal at www.UnitedHealthcare.com
- Call UnitedHealthcare Customer Care at 1-800-624-8822
- Call the UnitedHealthcare Provider Advocate assigned to the UM delegate
Documentation Tools for Success
GENERAL
- HEALTH HISTORY – Adult
- HEALTH PROFILE – Adult
- HEALTH PROFILE – Pediatric/Adolescent
- MEDICATION PROFILE – Continuation
PEDIATRIC
WELL CHILD
- 1 month & under
- 2-3 Months
- 4 Months
- 6 Months
- 9 Months
- 12 Months
- 15 Months
- 2 Years
- 3 Years
- 4-5 Years
- 6-8 Years
- 9-12 Years
WELL ADOLESCENT
ADULT
FEMALE ADULT
MALE ADULT
AB 1455
What is AB 1455?
Assembly Bill 1455 is legislation that requires a Health Plan and its providers to establish a fast, fair and cost-effective Dispute Resolution Mechanism to process and resolve contracted and non-contracted provider disputes. The document below describes Physicians Medical Group of San Jose’s process.
Provider Dispute Resolution Request
Other Forms
- Advance Healthcare Directive (English)
- Authorization Request Form
- Claims Follow-up Inquiry Form
- CuraScript Pharmacy Fax Form
- Eligibility Waiver Form
- Explanation of Adjustment Reason Codes
- Initial Health Assessment Forms
- Provider Dispute Resolutions Request Form
- Subscriber/Member Information Request Form
- Sample Policies and Procedures
- W-9 Request for Taxpayer Indentification Number and Certification Form
- Request-Refusal for interpretive Services Form
- Member Grievance Forms and Links
- Privacy Practices
Health Net
- Decision Power Referral Pad Request Form
- Introduction to Comprehensive Perinatal Services Program
- 2005/2006 Claims Submissions