P.O. BOX 11033, ORANGE, CA 92856 Phone: 714-246-8686
ADULT TRANSPLANT NOTIFICATION AND REQUEST FORM
*Transplants for children under the age of 21, refer to California Children’s Services (CCS)
Fax Submissions: Urgent: 714-796-6616 Routine: 714-796-6607
PHASE:
New Referral Evaluation Listed Transplant Post-Transplant
*** IN ORDER TO PROCESS YOUR REQUEST, ARF MUST BE COMPLETED AND LEGIBLE ***
PROVIDER: Authorization does not guarantee payment; ELIGIBILITY must be verified at the time services are
rendered.
Patient Name: ___________________________________________________________________ M F D.O.B. ________________ Age: ________________
Last First
Mailing Address: _____________________________________________ City: _____________________________ ZIP: _______________ Phone: ________________
Client Index # (CIN): _________________________________
Referring Provider:
Provider NPI#: ________________TIN#: ________________
Medi-Cal ID#: ______________________________________
Address: Phone: ________________
Fax: __________________
Office Contact: ______________________________________
Physician’s Signature: ________________________________
Diagnosis: ___________________________ ICD-9: _________
TRANSPLANT TYPE
(CalOptima may redirect based on contract status or center
availability)
BMT:
DLI:
Kidney:
Kidney Pancreas:
Liver:
Liver and Kidney:
Lung:
Heart:
Heart and Lung:
Small Bowel:
Cedars
Cedars
UCI
California Pacific
Cedars
Cedars
USC
Cedars
Stanford
Cedars
UCSF
USC
USC
USC
USC
AUTHORIZATION REQUEST
Inpatient Estimated Length of Stay: ___________________________________________
Outpatient Letter of Agreement (LOA) Requested
Date(s) of Service: ____________________________________ Retro Date(s) of Service: ____________________________________
List ALL procedures requested along with the appropriate CPT/HCPCS
REQUESTED PROCEDURES PERTINENT HISTORY (Submit supporting medical records) CODE (CPT or HCPCS) QUANTITY (REQUIRED)
DO NOT WRITE BELOW THIS LINE FOR CalOptima USE ONLY
STATUS
Authorization Number #
Approved Modified Denied Signature: Date:
Not Medically Indicated Not a Covered Benefit Comments:
Services Available In Network
Revised 03.18.2013
