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Forms

Find all the documents you need at the moment you need them with this handy library of forms and resources.

 

Medical referral and prior authorization request form (Independent)

If a service requires prior authorization, independent providers should fill out this form and fax it to 619.740.8111 to receive approval before scheduling a procedure. Providers who are rendering care to members assigned to a Plan Medical Group (PMG) should contact the PMG for prior authorization.

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Pre-certification form for point-of-service (POS) plans

If a member has a POS Plan and requires pre-certification for their services, fill out this form and fax it to 619.740.8111 prior to delivering care.

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Pharmacy prior authorization request

If a medication requires prior authorization, fill out this form and fax it to 1.858.357.2534 for review.

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Forms for Medicare members

Here are the forms you need to care for Medicare-eligible members of Sharp Health Plan.

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Member grievance / appeal form — English

Members who disagree with a utilization review decision or are dissatisfied with the care they have received, have the right to file a grievance or appeal. Provide English-speaking members with this form to start the process.

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Member grievance / appeal form — Español

Provide Spanish-speaking members with this form to submit their grievance or appeal.

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Case management / disease management referral facsimile transmittal

Complete this form to refer a member to case management or disease management. Members can also refer themselves by calling 1.800.359.2002.

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EDI / ERA enrollment form

Use this form to request an electronic data interchange (EDI) for claims submission and electronic remittance advice (ERA) in place of paper Evidence of Benefits (EOBs) and checks.

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Member enrollment and faxed prescription form

When members need specialty prescription medications, use this Diplomat Specialty Pharmacy form to fill new prescriptions, authorize refills, or when a PA extension is required.

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Acupuncture referral authorization request form

If members have coverage through Covered California® or CaliforniaChoice® (CalChoice), they may need a referral for acupuncture. Use this form to request authorization.

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Provider dispute resolution request form

Before we can assist you in the resolution process, we’ll need you to fill out this brief form with your information, patient details, and your description of the dispute.

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Member dismissal request form

This form may be used to request dismissal of a Member from your care. Please refer to our policy on Provider-Initiated Member Dismissal in our Provider Operations Manual prior to completing or submitting this form. Once complete, fax to Customer Care at 619.740.8571 or send vial mail to the address on the form.

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