Updated August 7 COVID-19 Info for members, providers and resource center visitors.

Prior Authorization Request Forms

Prior Authorization Request Forms are available for download below. Please select the appropriate Prior Authorization Request Form for your affiliation.

If your Member/Patient is in the L.A. Care Direct Network…

Use the L.A. Care Direct Network Prior Authorization Fax Request Form

Or enter your authorization using the online iExchange portal.

Questions? Review the Direct Network iExchange Training FAQ

If your Member/Patient is with one of the following Participating Physician Groups…
  • Allied Pacific IPA
  • AltaMed Health Services Corporation
  • Angeles IPA
  • AppleCare Medical Group, St. Francis, Inc
  • AppleCare Medical Group, Inc. Select Region, Downey and Whittier
  • Axminster Medical Group
  • Bella Vista IPA
  • Citrus Valley Physician Group
  • Community Family Care
  • Community Family Care – Antelope Valley
  • Crown City Medical Group
  • Department of Health Services (DHS)
  • El Proyecto Del Barrio, Inc
  • Exceptional
  • Family Care Specialist IPA, A Medical Group Inc.
  • Global Care IPA
  • HealthCare Partners Medical Group
  • High Desert Medical Group
  • Lakeside Medical Group
  • OmniCare Medical Group
  • Pioneer Provider Network, A Medical Group, Inc
  • Pomona Valley Medical Group
  • Prospect Healthsource Medical Group, Inc
  • Prospect Medical Group Los Angeles, Inc
  • Prospect Medical Group, Inc.
  • Regal Medical Group
  • Seaside Health Plan  
  • Sierra Medical Group
  • St. Vincent IPA
  • Superior Choice Medical Group
  • Universal Care Medical Group

If the PPG your Member/Patient is assigned to is not listed, please use the Prior Authorization Request Form below.

Use the Prior Authorization Request Form

If your Member/Patient is with Preferred IPA…

Use the Participating Physician Group (PPG) Prior Authorization Request Form

Or enter your authorization using the online iExchange portal.