Long-Term Care Treatment in Place Notication Form
Dates of Service Requested From: ____________________________ To: _____________________________
PROVIDER: Authorization does not guarantee payment.
CalOptima ELIGIBILITY must be veried at the time services are rendered.
Patient Name: _______________________________________
Male Female Date of Birth: _______________
Mailing Address: __________________________________________________ City: _______________ ZIP: _______
Phone: _____________________ CIN#: _______________
Facility Name: ___________________________________________________________________________________
Facility Address: __________________________________________________ City: _______________ ZIP: _______
Phone: ____________________ Fax: ____________________ Medi-Cal Provider ID#/NPI: ____________________
Diagnosis: _______________________________________________________ Physician’s Name: _______________
Signicant Signs and Symptoms of Acute Illness:
DO NOT WRITE BELOW THIS LINE FOR CalOptima USE ONLY
COMMENTS:
Signature: __________________________________________ Date: _________________
Revised 09-17
P.O. Box 11045
Orange, CA 92856
Phone: 714-246-8444
Fax: 714-246-8843
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