Cal MediConnect Plan (Medicare-Medicaid Plan)
P.O. BOX 11033 ORANGE, CA 92856 Phone: 714- 246-8686
AUTHORIZATION REQUEST FORM (ARF)
ROUTINE RETRO OneCare Connect Fax 714-571-2440
*** IN ORDER TO PROCESS YOUR REQUEST, ARF MUST BE COMPLETE AND LEGIBLE ***
PROVIDER: Authorization does not guarantee payment. ELIGIBILITY must be verified at the time services are
Patient Name: ___________________________________________________________________ M F D.O.B. ________________ Age: ________________
Last First
Mailing Address: _____________________________________________ City: _____________________________ ZIP: _______________ Phone: ________________
Client Index # (CIN): __________________________________
Provider Rendering Service (Physician, Facility, Vendor):
Provider NPI#: ________________TIN#: ________________
Medi-Cal ID#: _________________________
Provider NPI#: ________________TIN#: ________________
Medi-Cal ID#: _________________________
Address: Phone: ________________
Address: Phone: ________________
Office Contact: ________________________________________
Physician’s Signature: __________________________________
Office Contact:________________________________________
Diagnosis: ____________________________________________ ICD-10: ____________________________________________
URGENT REQUEST Fax to 714-571-2440. ***Definition: “Urgent” is ONLY when normal time frame for authorization will be detrimental
to patient’s life or health, jeopardize patient’s ability to regain maximum function, or result in loss of life, limb or other major bodily function.
Urgent requests are addressed within 72 hours.***
Inpatient Facility Outpatient Facility SNF:
Retro Date(s) of Service ____________________________________
List ALL procedures requested along with the appropriate CPT/HCPCS and Supporting Documentation
REQUESTED PROCEDURES PERTINENT HISTORY (Submit supporting Medical Records) CODE (CPT or HCPCS) QUANTITY (REQUIRED)
Revised 2/15/2017
