Forms & Brochures
How to View and Download Files
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Pharmacy, Physician Certification Statement (PCS) Forms and Prior Authorization Forms
Commercial & Medi-Cal Plans
- Inpatient Prior Authorization – Commercial – English (PDF)
- Outpatient Prior Authorization – Commercial – English (PDF)
- Inpatient Prior Authorization – Medi-Cal (PDF)
- Outpatient Prior Authorization – Medi-Cal (PDF)
- Prescription Drug Prior Authorization or Step Therapy Exception Form – Commercial and Medi-Cal – English (PDF)
- PCS Form – Request for Transportation – Medi-Cal – English (PDF)
CalViva Health Plan
- Inpatient Prior Authorization Form – CalViva Health – English (PDF)
- Outpatient Prior Authorization Form – CalViva Health – English (PDF)
- Prescription Drug Prior Authorization or Step Therapy Exception Form – CalViva Health – English (PDF)
- PCS Form – Request for Transportation – CalViva Health – English (PDF)
Community Health Plan of Imperial Valley Plan
- Inpatient Prior Authorization Form – Community Health Plan of Imperial Valley – English (PDF)
- Outpatient Prior Authorization Form – Community Health Plan of Imperial Valley – English (PDF)
- Prescription Drug Prior Authorization or Step Therapy Exception Form – Community Health Plan of Imperial Valley – English (PDF)
- PCS Form – Request for Transportation – Community Health Plan of Imperial Valley – English (PDF)