Universal Provider Manual
L.A. Care offers its providers a Universal Provider Manual (UPM). The UPM serves to support our providers by helping you better understand our guidelines, policies and procedures, and to comply with applicable laws, rules, regulations, guidance, and accreditation standards.
The New Provider Orientation Handbook
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.
Care Management Referral Form
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 Community Supports (CS) Disenrollment Notification
MLTSS Referral Form
Nursing Facility Transition/Diversion Services: Service Authorization Request Form
Palliative Care Referral & Screening Tool
Preferred Language Labels (Sized for Avery 5160)
Interpretation Request/Refusal Labels (Sized for Avery 5160)
L.A. Care Medicare Plus (HMO-DSNP):
Quality Drug Clinical Care Form
Quality Drug Clinical Care Form (Spanish)
L.A. Care Covered/Direct & Homecare Workers Health Care Plan:
Postal Prescription Services Form
Postal Prescription Services Form (Spanish)
Visit our Pharmacy Services web page for more information.
Short Term Post-Hospitalization Service Authorization Request
Short Term Post Hospitalization Quick Reference Guide
Homeless and Housing Support Services Program (HHSS) Form
Community Supports Quick Reference Guide
Community Supports Day Habilitation Quick Reference Guide
Community Supports Day Habilitation Service Authorization Request
Homeless and Housing Support Services Program (HHSS) Reauthorization Form
Housing Deposits Quick Reference Guide
Housing Deposits Services Request for Funds Form
Housing Deposits Eligibility Criteria
Housing Navigation Eligibility Criteria
Tenancy Support Services Eligibility Criteria
Recuperative Care Community Supports Program Quick Reference Guide
Recuperative Care Prior Authorization Request Form
Request for Recuperative Care Extension Form
Recuperative Care Provider Contracted Network
Community Health Worker Benefit Recommendation Form
Community Health Worker Benefit Assessment Form
Asthma Remediation Certificate of Completion
Asthma Remediation Service Authorization Request
Asthma Remediation Quick Reference Guide
Asthma Remediation Letter of Permission
For more program information, visit Community Supports.
Provider Prior Authorization Tool
Prior Authorization Request Form
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)
Provider Authorization and Billing Reference Guide
Medi-Cal Shared Risk Amendment Template
Physician Certification Statement (PCS) form
L.A. Care Clinical Criteria Hierarchy
Emergency Department Protocols
BHT Authorization Form