Provider Support

Forms

General Forms

Provider Application Request Form

Medi-Cal, MCAP, MRMIP

Amendment to Participating Physician Agreement/Participating Physician Group Agreement

Staying Healthy Assessment Forms (Medi-Cal Only)

Prior Authorization Forms

Surveys

Medi-Cal Managed Care Policy Letters

Clinical and Preventive Care Tools

Adolescent Health QIP kit

Preventive Care Forms

Pediatric Preventive Care Guidelines

Provider Maintenance Form

Provider Maintenance Form

Having problems accessing this content? Please call your provider relation representative or the provider help line applicable to the member’s health plan.

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Anthem Blue Cross is the trade name of Blue Cross of California and Anthem Blue Cross Partnership Plan is the trade name of Blue Cross of California and Anthem Blue Cross Partnership Plan is the trade name of Blue Cross of California Partnership Plan, Inc. Independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County