AUTHORIZATION REQUEST FORM (ARF)
for Community-Based Adult Services (CBAS)
URGENT (72-hour Process) Fax to (714) 481-6422 ROUTINE Fax to (714) 481-6423
*** 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: ___________________________________________________________________ Sex: M F D.O.B. ________________ Age: ____________
Last First
Mailing Address: _____________________________________________ City: _____________________________ ZIP: _______________ Phone: ________________
Client Index # (CIN): __________________________________ Preferred Language (if applicable): _____________________________________________________
CBAS Provider Referring Service: CBAS Provider Rendering Service:
Provider NPI#: ________________TIN#: ________________
Medi-Cal ID#: ______________________________________
Provider NPI#: ________________TIN#: ________________
Medi-Cal ID#: ______________________________________
Address: Phone: ________________
Fax: __________________
Address: Phone: ________________
Fax: __________________
Office Contact: ________________________________________
Requestor Signature: ___________________________________
Office Contact:
______________________________________________________
Diagnosis: ____________________________________________ ICD-9/10: ____________________________________________
AUTHORIZATION REQUEST
Date(s) of Services: ____________________________________
List ALL procedures requested, along with the appropriate CPT/HCPCS
REQUESTED PROCEDURES PERTINENT HISTORY (Submit supporting Medical Records) CODE (CPT or HCPCS) QUANTITY (REQUIRED)
Day Services, Adult; Per Diem — Month of : S5102 Days
Day Services, Adult; Per Diem — Month of : S5102 Days
Day Services, Adult; Per Diem — Month of : S5102 Days
Day Services, Adult; Per Diem — Month of : S5102 Days
Day Services, Adult; Per Diem — Month of : S5102 Days
Day Services, Adult; Per Diem — Month of : S5102 Days
DO NOT WRITE BELOW THIS LINE FOR CalOptima USE ONLY
STATUS
Authorization Number #
Approved Signature: Date:
Denied Comments:
Modified
Deferred
Alternative Treatment
Affiliated Health Network:
Phone:
P.O. BOX 11033 ORANGE, CA 92856 Phone: (855) 227-1314
Rev. 3/2015
