For CalOptima Use Only For CalOptima Use Only
REFERENCE NO: Status: Approved as Requested Denied
Approved as Modified Deferred
P.O. BOX 11045
ORANGE, CA 92856
Phone: (855) 227-1314
Email:
cbasteam@caloptima.org
Benefit Inquiry for Community-Based Adult Services (CBAS)
Routine Request Fax Number:(714) 481-6423 Expedited Request Fax Number: (714) 481-6422
SECTION I
Patient Name:
M F
D.O.B. Age:
Last First
Mailing Address: City: ZIP: Phone No:
CIN/Medi-Cal #: Preferred Language:
Alternate Contact (Family Member/Caregiver): Phone No:
SECTION II If CBAS Center Inquiry, NPI#:
CBAS PCP HN/PMG CalOptima CBO Facility (Acute/SNF) Health Risk Assessment (HRA)
Requestor Name:
Telephone Number: Email:
Address:
Relationship to Patient:
Requestor Signature (PCP/CM):
SECTION III SECTION IV
Information Regarding Patient’s Need for Services: Additional Comments:
DO NOT WRITE BELOW THIS LINE
For CalOptima Use Only:
________________________________________________________________________________________________________________
________________________________________________________________________________
Signature: Date: Phone Number:
Rev.12/2014
