REQUEST FOR LETTER OF AGREEMENT
CalOptima UM Department Fax: 714-796-6654
(Sections 1 through 4 must be fully completed in order for request to be processed. Incomplete requests will be returned.)
Revision 12/14/16
1
Contact Submitting LOA Request
Date Submitting Request To CalOptima:
Health Network Contact Submitting LOA Request (first and last name):
Health Network Contact Phone #: Fax #:
Health Network Contact Email Address:
S
2
Last Name: First Name: Middle Initial:
CIN #: DOB:
Line of Business: Medi-Cal OneCare Connect OneCare
Health Network:
SECTION 3
Facility: Hospital ASC SNF (short stay) Dialysis Center
Professional (e.g., Neurology, Urology, Oral Surgery) Specialty:
Ancillary (e.g., DME, Home Health Agency, Transportation) Type:
Other provider type not listed above:
Provider Name: Provider NPI:
Provider Address:
Provider Contact Information for LOA: Name: Title:
Telephone #: Fax #:
SECTION 4
Health Network Authorization # (s): Place Of Service: Outpatient Inpatient
(Attach copy of authorization)
Authorization Start Date: Authorization End Date:
Expected DOS Beginning (prospective admit):
Description of Authorized Service(s) including CPT/HCPCS Codes # of units:
Reason for Referral/Comments:
Continuity of Care
SECTION 5
(CalOptima
use only)
For CalOptima Internal Use Only
Approved By CalOptima Medical Director: Date:
Approved By CalOptima Director of Contracting (or designee): Date:
