Provider Manuals
To help you better understand our guidelines, policies and procedures, L.A Care issues a manual to its providers each year. You can review a PDF version by selecting the appropriate manual on the Resources links.
Provider Forms
Below are the most frequently requested forms for L.A. Care Providers. If you have a suggestion for how we can improve any of the available forms, please contact Provider Support.
Functional Behavioral Assessment/Progress Report
Visit our Behavioral Health web page for program information.
ECM Benefit Member Referral Form
Learn more program information at Enhanced Care Management.
Caregiver Support Services: Service Authorization Request Form
CBAS Face to Face Assessment Request (CEDT) Form
Environmental Accessibility Adaptations (EAA) Service Authorization Request (SAR) Form
Environmental Accessibility Adaptations (EAA) Qualified Lead Form
Environmental Accessibility Adaptations (EAA) Physician Order Form
MLTSS Referral Form
Palliative Care Referral & Screening Tool
Preferred Language Labels (Sized for Avery 5160)
Interpretation Request/Refusal Labels (Sized for Avery 5160)
MedWatch Form
Ralphs Pharmacy Form
Ralphs Pharmacy Form (Spanish)
Visit our Pharmacy Services web page for more information.
Provider Portal Reference Guide
Go to the Provider Portal.
ELDA Technical Bulletin
Coding Reference Guide for Acute Respiratory Conditions
Provider Authorization and Billing Reference Guide
Medi-Cal Shared Risk Amendment Template
SNF Authorization and Billing Guidance
Hospital UM Related Fax Information for All L.A. Care Members
SNF Related Fax Information for All L.A. Care Members
Homeless and Housing Support Services Program (HHSS) Form
Homeless and Housing Support Services Program (HHSS) Reauthorization Form
Housing Deposits Quick Reference Guide
Housing Deposits Services Request for Funds Form
L.A Care HHSS Community Supports Program Quick Reference Guide
L.A. Care Recuperative Care Community Supports Program Quick Reference Guide
Recuperative Care Prior Authorization Request Form
Request for Recuperative Care Extension Form
Community Health Worker Benefit Recommendation Form
For more program information, visit Community Supports.
Provider Prior Authorization Tool
Prior Authorization Request Forms
Difficult Placement Authorization Request Form
Difficult Placement Authorization Request Form Checklist
Higher Level of Care (HLOC) Authorization Form
Hospital Priority & Type of Clinical Service Requested Fax Form
Hospital UM Contact Information (Authorization Contact Cheat Sheet)
SNF UM Contact Information (Authorization Contact Cheat Sheet)
SNF Authorization and Billing Guidance
Provider Authorization and Billing Reference Guide
Medi-Cal Shared Risk Amendment Template
Physician Certification Statement (PCS) form