Forms

• ABA 6 Month and Exit Progress Report Template (Word)
• ABA Exit Letter Template (Word)
• ABA Service Hour Log (Word)
• ABA School BHT Services Request Form (Word)
• Authorization Release of Information Form - English (PDF)
• Authorization Release of Information Form - Spanish (PDF)
• Behavioral Health Authorization Request Form (PDF)
• BHT Social Skills Template (Word)
• Coordination of Care Treatment Plan Form (PDF)
• No Further Treatment Request Form (PDF)
• Psych Testing Battery Plan (for Psychologist use only) (PDF)
• (For BH Providers Only) Transition of Care Tool (PDF)

For Integrated Denial Notices please click here .

Please select on the links below to obtain the revised CMS 1500 form (version 02/12) and the CMS 1500 Reference Instruction Manual.

• Acknowledgement Letter (Word)
• Capitation Data File Format (Word)
• Capitation Payment Deduction (Word)
• Cease and Desist Letter (Word)
• Claims Project Spreadsheet (Excel)
• Clean Claim Tool Guide - UB04 Inpatient Form (PDF)
• Clean Claim Tool Guide - UB04 Outpatient Form (PDF)
• CMS 1500 Reference Instruction Manual (PDF)
• Demand For Payment Letter (Word)
• Determination Letter (Word)
• Encounter Data CAP Request Letter (Word)
• Encounter Data Penalty Letter (Word)
• Hospital Directed Payment Dispute Form (Word)
• ICE - Claim Denial Reason Guide - IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid) (Word)
• Irrevocable Letter of Credit (Word)
• Manifest Report (Word)
• Medi-Cal Universe Layout Instructions (Word)
• Notice of CAP Deductions (Word)
• Notice of Denial of Payment - English (Word)
• Notice of Denial of Payment - Spanish (Word)
• Notice of Dismissal of Appeal Request (PDF)
• Part C Organization Determinations, Appeals, and Grievances (ODAG) (PDF)
• Payment Attestation (Word)
• Provider Identified Overpayment Form (PDF)
• Provider Identified Overpayment Form (Multiple) (PDF)
• IEHP DualChoice (HMO D-SNP) Provider Dispute Resolution (PDR) (Word) 
  
• Medi-Cal Provider Dispute Resolution (PDR) (Word)
• Remittance Advice - Medicare DualChoice Annual Visit (PDF)
  
• Revised CMS 1500 Health Insurance Claim Form (PDF)
• Sample Capitation Report (PDF)
• Waiver of Liability Statement - IEHP Dual Choice (HMO D-SNP) - effective January 2023 (PDF)
• Table 3 Payment Organization Determinations and Reconsiderations (PYMT_C) (PDF)

• DHCS Privacy Incident Report (PDF)
• Notice of Privacy Practices (Word)
• IEHP Code of Business Conduct and Ethics (PDF)

• Focus Group Incentive (FGI) - Request for Approval Form (Word)
• Focus Group Incentive (FGI) - Evaluation Form (Word)
• Member Incentive (MI) Program - Request for Approval (Word)
• Member Incentive (MI) Program - Annual Update/End of Program Evaluation (Word)
• Survey Incentive (SI) - Request for Approval Form (Word)
• Survey Incentive (SI) - Evaluation Form (Word)

Nondiscrimination Language Access Notice:

• Medi-Cal (PDF)
• Medicare (PDF)

• Biographical Information Sheet
• Credentialing DOA Audit Tool
• HIPAA Security - Medi-Cal DOA
• HIPAA Security - Medicare
• Medi-Cal DOA Tool UM/CM/QI
• Medicare DOA Tool UM/CM/QI
• Medi-Cal UM Referral Template
• Sub-Contracted Facility/Agency Services and Delegated Functions
• Approved Referral Audit Tool (Excel)
• California Specific - Reporting Requirements (PDF)
• Care Coordinator to Member Ratio Template 5.1 (Excel)
• Care Coordinator Training for Supporting Self-Direction (Excel)
• Care Management California Children's Services Review Tool (PDF)
• Care Transition Cases Log (Excel)
• Credentialing and Recredentialing Report for Delegated Networks (Excel)
• Credentialing and Recredentialing Report (Excel)
• Delegation Oversight Audit Preparation Instructions - IEHP DualChoice (Word)
• Delegation Oversight Audit Preparation Instructions - Medi-Cal (NCQA) (Word)
• Delegation Oversight Audit Preparation Instructions - Medi-Cal (Word)
• Denial Log Review Tool - IEHP DualChoice (Excel)
• Denial Log Review Tool - IEHP Medi-Cal (Excel)
• DOA CAP Response Form (Excel)
• Enrollee Protections Reporting Template, CA2.1 (Excel)
• IEHP ASM File Template (Excel)
• IEHP Universe Expedited Auth MESAR Data Dictionary (PDF)
• IEHP Universe Expedited Auth MESAR Template (Excel)
• IEHP Universe M_Claims Data Dictionary (PDF)
• IEHP Universe M_Claims Template (Excel)
• IEHP Universe M_SAR Table 1 Standard and Expedited Service Authorization Requests (Excel)
• IEHP Universe PYMT_C Table 3 Payment Organization Determinations and Reconsiderations (Excel)
• IEHP Universe Standard Auth MSSAR Data Dictionary (PDF)
• IEHP Universe Standard Auth MSSAR Template (Excel)
• IPA Care Management Review Tool - IEHP DualChoice (PDF)
• IPA Delegation Agreement - IEHP DualChoice (Word)
• IPA Delegation Agreement - Medi-Cal (Word)
• IPA Performance Evaluation Tool (Excel)
• Medi-Cal Care Coordination Review Tool (PDF)
• Medi-Cal Monthly Care Management Log (PDF)
• Medi-Cal SPD Review Tool Data Dictionary (PDF)
• MM Capitated Financial Alignment Model Reporting Requirements (PDF)
• Monthly CCS Referral Log 2.0 (PDF)
• Monthly Medicare Care Management Log 2.3 (PDF)
• Monthly Medicare Plan Outreach Log 1.1 (PDF)
• Practitioner Profile Template (Excel)
• Precontractual Audit Preparation Instructions - IEHP DualChoice (Word)
• Precontractual Audit Preparation Instruction - Medi-Cal (Word)
• Program Description - Denial letter Sanction - IEHP DualChoice (PDF)
• Referral Universe (Excel)
• Request for UM Criteria Log (Word)
• Response to Request for UM Criteria Letter (Word)
• Second Opinion Tracking Log (Word)

The Grievance Forms below are for your Member's use when filing a complaint, or has an appeal regarding any aspect of care or service provided by you. Please select the Appeal and Grievance form appropriate for their use:

• Medi-Cal Form
  English (PDF)         Spanish (PDF)         Chinese (PDF)         Vietnamese (PDF)

• Medicare Form
  English (PDF)         Spanish (PDF)         Chinese (PDF)         Vietnamese (PDF)

The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023:

English (PDF)         Spanish (PDF)         Chinese (PDF)         Vietnamese (PDF)

• Appeal Resolution Process - Medi-Cal - [English] (Word)
• Appeal Resolution Process - Medi-Cal - [Spanish] (Word)
• Grievance Resolution Process - Medi-Cal - [English] (Word)
• Grievance Resolution Process - Medi-Cal - [Spanish] (Word)
  
• Provider Fair Hearing Process (Word)
• Provider Grievance Acknowledgement Letter (Word)
• Provider Grievance Resolution Letter (Word)

Inland Empire Health Plan (IEHP) offers you easy access to useful reference materials and forms you may need. It's just one click away. Select the growth chart form that you need by clicking on the link below:

• (0-36 months): Head Circumference-For-Age And Weight- For-Length Percentiles
  Boys (PDF)          Girls (PDF)

• (0-36 months): Length and Weight-For-Age Percentiles
  Boys (PDF)          Girls (PDF)

• (2-20 years): Stature and Weight-For-Age-Percentiles
  Boys (PDF)          Girls (PDF)

• (2-20 years): Body Mass Index For-Age Percentiles
  Boys (PDF)          Girls (PDF)

• Historical Data Form (Word)

• Early Start (0-36 months) Referral (PDF)
• Early Start Online Application
• Eligibility and Intake

• IRC Referrals (3-99+ years):
  • San Bernardino County: For Providers - (909) 890-4711 // Intake - (909) 890-3148
  • Riverside County: For Providers - (909) 890-4763 // Intake - (951) 826-2648

A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by DHCS .

Click on the title to expand the menu and download desired document.

A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by CMS.

Click on the title to expand the menu and download desired document.

These templates should not be used until the effective date of January 2, 2023. Please continue using the current Medicare DualChoice letter templates currently seen on this webpage for the remainder of 2022.

A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by CMS.

Click on the title to expand the menu and download desired document.

Certificates of Medical Necessity (CMN) & DME Information Forms (DIF)

• Positive Airway Pressure Devices for Obstructive Sleep Apnea (PDF)
• Enteral and Parenteral Nutrition (PDF)
• External Infusion Pump (PDF)
• Osteogenesis Stimulators (PDF)
• Oxygen (PDF)
• Seat Lift Mechanisms (PDF)
• Continuation Form (PDF)
• Transcutaneous Electrical Nerve Stimulator (TENS) (PDF)
• Pneumatic Compression Device (PDF)

To submit a referral to IEHP, please fill out the referral form below, include all clinical notes and fax it to IEHP. If you are referring back to yourself, please indicate such. If you need IEHP to direct the referral, please indicate that on the form.

• Referral Authorization Request Form - Non-Contracted Providers (PDF)

If you are interested in becoming a network Provider, please click here.

IEHP provides standard risk assessment forms that can be used by all Providers of obstetrical (OB) services. Please refer to IEHP Provider Policy 10D1, "Obstetrical Services, Guidelines for Obstetrical Services" for further detail. To obtain copies, simply click on the links below.

• Edinburgh Postnatal Depression Screening Tool - English (PDF)
• Edinburgh Postnatal Depression Screening Tool - Spanish (PDF)
• ACOG Antepartum Record (PDF)
• California Prenatal Screening Program (PDF)
• Contraceptive Informed Choice Form - English (Word)
• Contraceptive Informed Choice Form - Spanish (Word)
• Initial Perinatal Risk Assessment Form - English (Word)
• Initial Perinatal Risk Assessment Form - Spanish (Word)

• Click here for Pharmacy forms.

• Part D Excluded Provider Letter - English (Word)
• Part D Excluded Provider Letter - Spanish (Word) 
• Prescription Transition Notice - English (PDF)
• Prescription Transition Notice - Spanish (PDF)
• Request for Addition or Deletion of a Drug to the Formulary (PDF)

By clicking on these links, you will be leaving the IEHP website.

On May 23,2017, the Department of Healthcare Services (DHCS) released All Plan Letter (APL) 17-009, reporting requirements related to Provider Preventable Conditions. In conjunction, DHCS released Dual Plan Letter (DPL) 17-002. As part of these instructions, the Health Plan, Network Providers, Delegates, Contracted Hospitals, and ambulatory surgical centers must report using PPC Form on DHCS secure online portal for both Medicare and Medi-Cal lines of business.

Further information is available on the following pages:

• Instructions for Completing Online Reporting of PPCs
• Medi-Cal Guidance on Reporting Provider-Preventable Conditions
• Frequently Asked Questions
• All Plan Letter (APL) 17-009
• Duals Plan Letter (DPL) 17-002
• PPC Form

Medicare and Medi-Cal lines of business must follow the instructions below:

1. Providers are REQUIRED to send a copy of the completed PPC submission from the DHCS secure online portal to IEHP by fax at (909) 890-5545 within five (5) business days of reporting to DHCS;
2. IEHP does not pay Provider claims nor reimburse a Provider for a PPC, in accordance with 42 CFR Section 438.3(g) and IEHP's three-way Cal MediConnect contract. Per IEHP policy and the Coordinated Care Initiative 3-Way Contract, IEHP reserves the right to recover or recoup any claim related to a PPC;
3. As outlined in both the APL/DPL - Reporting Requirements related to Provider Preventable Conditions, the following classify as PPCs and must be reported:

Category 1 - HCACs (For Any Inpatient Hospital Setting in Medicaid)

• Any unintended foreign object retained after surgery
• A clinically significant air embolism
• An incidence of blood incompatibility
• A stage III or stage IV pressure ulcer that developed during the patient's stay in the hospital
• A significant fall or trauma that resulted in fracture, dislocation, intracranial injury, crushing injury, burn, or electric shock
• A catheter-associated urinary tract infection
• Vascular catheter-associated infection
• Any of the following manifestations of poor glycemic control: diabetic ketoacidosis; nonketotic hyperosmolar coma; hypoglycemic coma; secondary diabetes with ketoacidosis; or secondary diabetes with hyperosmolarity
• A surgical site infection following:
  • Coronary artery bypass graft (CABG) - mediastinitis
  • Bariatric surgery; including laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery
  • Orthopedic procedures; including spine, neck, shoulder, elbow
  • Cardiac implantable electronic device procedures
• Deep vein thrombosis/pulmonary embolism following total knee replacement or hip replacement  with pediatric and obstetric exceptions
• Latrogenic pneumothorax with venous catheterization
• A vascular catheter-associated infection

Category 2 - Other Provider Preventable Conditions (For Any Health Care Setting)

• Wrong surgical or other invasive procedure performed on a patient
• Surgical or other invasive procedure performed on the wrong body part
• Surgical or other invasive procedure performed on the wrong patient

• Telehealth Patient Consent Form - English (PDF)
• Telehealth Patient Consent Form - Spanish (PDF)
• Telehealth Patient Consent Form - Chinese (PDF)
• Telehealth Patient Consent Form - Vietnamese (PDF)
• DPP Rx Pad (PDF)

• Acute Hospital Discharge Needs Request Form (PDF)
• Acute Inpatient Data Sheet (Word)
• Advance Health Care Directive - [English] (PDF)
• Advance Health Care Directive - [Spanish] (PDF)
• Advance Health Care Directive FAQs - [English] (Word)
• Advance Health Care Directive FAQs - [Spanish] (Word)
• Authorization or Refusal to Release Medical Record - Out of Network Family Planning - [English] (PDF)
• Authorization or Refusal to Release Medical Record - Out of Network Family Planning - [Spanish] (PDF)
• Authorization for Use and/or Disclosure of Patient Health Information - English (PDF)
• Authorization for Use and/or Disclosure of Patient Health Information - Spanish (PDF)
• Behavioral Health Hospital Survey - Corrective Action Plan Tool (PDF)
• Behavioral Health Hospital Survey Tool (PDF)
• California Minor Consent and Confidentiality Laws (PDF)
• Care Management Referral Form (PDF)
• CCS-GHPP Client Service Auth Request - Established Case (PDF)
• CCS-GHPP Client Service Auth Request - New Case (PDF)
• Consent for HIV Test - English (PDF)
• Consent for HIV Test - Spanish (PDF)
• Consent for Special Procedure - English (Word)
• Consent for Special Procedure - Spanish (Word)
• Corrective Action Plan Notification Tool (PDF)
• Desert AIDS Project Enrollment Form (PDF)
• DMHC Provider Appointment Availability Survey Methodology (PDF)
• DMHC Provider Appointment Availability Survey Tools (PDF)
• GHPP Application to Determine Eligibility (PDF)
• Health Plan Referral Form for Out-of-Network and Special Services (Word)
• Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - English (PDF) - effective 1/1/2023
• Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Spanish (PDF) - effective 1/1/2023
• Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Chinese (PDF) - effective 1/1/2023
• Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Vietnamese (PDF) - effective 1/1/2023
• HIV Testing Sites - Riverside and San Bernardino (PDF)
• Home Health Check Off List (PDF)
• Home Modification Consent Form - English (PDF) - effective 04/01/2023
• Home Modification Consent Form - Spanish (PDF) - effective 04/01/2023
• Home Modification Consent Form - Chinese (PDF) - effective 04/01/2023
• Home Modification Consent Form - Vietnamese (PDF) - effective 04/01/2023
• IEHP Medical Record Review Survey Addendum (PDF)
• Interim Facility Site Review (Assessment) Tool  (PDF)
• Interim Facility Site Review (On-Site) Tool  (PDF)
• Long Term Care (LTC) Follow-Up Review Form (Word)
• Long Term Care Initial Review Form (Word)
• Long Term Care (LTC) Data Sheet (PDF)
• MC 171 Form and Instruction 05-07 (PDF)
• Medi-Cal FFS-Approved Transplant Centers of Excellence (PDF)
• Medicare Non-Covered Benefits (Word)
• My Path Palliative Care Program CAP Form (PDF)
• Non-Emergency Medical Transportation (NEMT) Physician Certification Statement (PCS) (PDF)
• PCP Referral Tracking Log (Word)
• Periodicity Schedule - Dental (PDF)
• Provider Appointment Availability Survey Manual (PDF)
• Referral Audit CAP Notification Letter (Word)
• Referral Audit Corrective Action Plan Tool (Word)
• Referral Form (PDF)
• Reportable Diseases and Conditions - Riverside (PDF)
• Reportable Diseases and Conditions - San Bernardino (PDF)
• Service Request Form for Skilled Nursing Facilities (PDF)
• Service Request for Skilled Nursing Facilities (PDF)
• SNF Initial Review (PDF)
• SNF Follow-up Review (PDF)
• Specialty Office Service Authorization Sets Grid (Word)
• Standing Referral and Extended Access Referral to Specialty Care (PDF)
• Sterilization Consent Form PM-330
  PM-330 Form - Tips and Example (PDF)
  PM-330 Form - English (PDF)
  PM-330 Form - Spanish (PDF)
• Transplant Team Referral Form (Word)
• Transportation Requests Form (SNF & LTC) (PDF)
• Transportation Requests Form (Hospital) (PDF)
• UM Timeliness Standards - IEHP DualChoice (PDF)
• UM Timeliness Standards - Medi-Cal (Word)
• Urgent Care CAP Complete Tool and Notification Letter (PDF)
• Wound Assessment - Admission (PDF)
• Wound Assessment - Follow - Up (PDF)
• Wound Assessment - Addendum (PDF)

• Ophthalmologist Referral Form (PDF)
• Vision Exception Request (VER) Form (PDF)
• PCP Vision Report Form (PDF)
• IEHP Lab Form (PDF)
• Medi-Cal Non-Covered Services/Materials Waiver Form-English (PDF)
• Medi-Cal Non-Covered Services/Materials Waiver Form-Spanish (PDF)
• Medi-Cal Non-Covered Services/Materials Waiver Form-Chinese (PDF)
• Medi-Cal Non-Covered Services/Materials Waiver Form-Vietnamese (PDF)

 The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023:

• IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-English (PDF)
• IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Spanish (PDF)
• IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Chinese (PDF)
• IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Vietnamese (PDF)

• AEVS Alpha Codes (PDF)
• Attachment I - Statement of Agreement by Supervising Provider (PDF)
• Authorization of Release - Use & Disclosure of PHI - English (PDF)
• Authorization of Release - Use & Disclosure of PHI - Spanish (PDF)
• Bariatric Surgeon Case Volume Attestation (PDF)
• BIC Card (Word)
• Change in Hospital Affiliation Letter (Word) 
• Change in IPA Affiliation Letter (Word)
• Chronic Care Improvement Program (CCIP) Planning & Reporting Document (Word)
• Corrective Action Plan Notification Tool (Word)
• CMS 1696 Appointment of Representative - English (PDF)
• CMS 1696 Appointment of Representative - Spanish (PDF)
• Compliant Termination Letter (Word)
• Contract Maintenance Request Form (PDF)
• Coverage Determination Form - Provider and Member - [Chinese] (Word)
• Coverage Determination Form - Provider and Member - [Spanish] (Word)
• Credentialing Subcommittee Termination Letter (PDF)
• Death Master File Identity Attestation (PDF)
• Delegation of Services Agreement and Supervising Physician Form (PDF)
• DHCS MMCD Facility Site Review (FSR) Standards (PDF)
• DHCS MMCD Facility Site Review (FSR) Tool (PDF)
• DHCS MMCD FSR Attachment 0C - Physical Accessibility Review Survey (Word)
• DHCS MMCD FSR Attachment 0D - Ancillary Physical Accessibility Review Survey (PDF)
• DHCS MMCD FSR Attachment 0E - CBAS Physical Accessibility Review Survey (PDF)
• DHCS MMCD Medical Record Review (MRR) Standards (PDF)
• DHCS MMCD Medical Record Review (MRR) Tool (PDF)
• DualChoice - TPL Authorization Release Form (PDF)
• Frozen Enrollment Change Status (Word)
• Hospital Admitting Arrangement Attestation - Admitter (PDF)
• Hospital Admitting Arrangement Attestation - Admitting Physician (PDF)
• Hospital Admitting Arrangement Attestation - Hospitalist (PDF)
• Hospital Admitting Privileges Reference by Specialty (PDF)
• Hospital Geographic Service Areas (Word)
• IEHP Addendum E (PDF)
• IEHP ID Card - Medi-Cal (PDF)
• IEHP ID Card - DualChoice (PDF)
• IEHP Interim Facility Site Review Tool (Word)
• IEHP Medical Record Review Survey Addendum (PDF)
• IEHP Urgent Care Center Evaluation Tool (PDF)
• IEHP PCP Leave of Absence Coverage Form (Word)
• IEHP Peer Review Level I and Credentialing Appeal (PDF)
• IEHP Peer Review Process and Level II Appeal (PDF)
• IPA Hospital Link Responsibility Grid - IEHP DualChoice (Excel)
• IPA Hospital Link Responsibility Grid - Medi-Cal (PDF)
• Licensed Midwife Attestation (PDF)
• Limited Enrollment Change Status (Word)
• Member PCP Termination Notification Letter - [English] (Word)
• Member PCP Termination Notification Letter - [Spanish] (Word)
• Non-Compliant Termination Letter (Word)
• Over Enrollment Change Status (Word)
• Patient Transfer Agreement (PDF) 
• Peer Review Termination Letter (PDF)
• Persons with Disabilities Workgroup Application (Word)
• Plan Choice Form - Riverside - English - Medi-Cal (PDF) 
• Plan Choice Form - Riverside - Spanish - Medi-Cal (PDF)
• Plan Choice Form - SB - English - Medi-Cal (PDF)
• Plan Choice Form - SB - Spanish - Medi-Cal (PDF)
• Prescribing Arrangements for DEA and CDS Eligible Practitioners (PDF)
• Provider Preventable Conditions (Word)
• Provider Privilege Adjustment Request Form (PDF)
• Specialty Network Review (PDF)
• Specialty Network Review - IEHP Initial Findings Template (Excel)
• Specialty Network Review - IPA Response Template (Excel)
• The Code of Conduct of the Persons with Disabilities Workgroup (Word)
• Transgender Questionnaire (PDF)
• Urgent Care CAP Complete Tool and Notification Letter (Word)
• Verification of Qualifications for HIV/AIDS Physician Specialists (PDF)
• Work History Form Past Five (5) Years' Request (PDF)
• 2017 Model Output Report (MOR) Data File Layout (PDF)