Fillable SAR Fax Cover Sheet 06.2020 (Department of Health Care Services)

Fill Online, Printable, Fillable, Blank SAR Fax Cover Sheet 06.2020 (Department of Health Care Services) Form

Use Fill to complete blank online DEPARTMENT OF HEALTH CARE SERVICES (CALIFORNIA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

SAR Fax Cover Sheet 06.2020 (Department of Health Care Services)

On average this form takes 4 minutes to complete

The SAR Fax Cover Sheet 06.2020 (Department of Health Care Services) form is 1 page long and contains:

  • 0 signatures
  • 18 check-boxes
  • 8 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Department of Health Care Services (California) forms online.

BROWSE DEPARTMENT OF HEALTH CARE SERVICES (CALIFORNIA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Department of Health Care Services │ Integrated Systems of Care Division │1515 K Street, Sacramento, CA 95814
Integrated Systems of Care Division
Service Authorization Request (SAR)
Fax Cover Sheet
Date: Phone Number:
Route To: Email:
From:
CCSCriticalReview@dhcs.ca.gov
Fax Number: (916) 440-5306
CCSGeneralProcessing@dhcs.ca.gov
Fax Number: (916) 440-5768
URGENT SARs (Critical Review) NON-URGENT SARs (General Processing)
Audiology
Blood Factor and Hemlibra
Out of State (OOS) Request Durable Medical Equipment (DME)
Transplant Genetic Testing
OTHER:
Neonatal Intensive Care Unit (NICU)
Specialty Drugs: CAR-T: Yescarta, Kymriah
Specialty Drugs: Cystic Fibrosis: Kalydeco,
Orkambi, Symdeko, Trikafta
Specialty Drugs: Growth Disorders: Lupron,
Histrelin, Triporelin
Specialty Drugs: High-Risk Infants: Synagis
Specialty Drugs: Metabolic Diseases: Kuvan,
Palynziq, Brineura, medical foods, enteral nutrition
products
Specialty Drugs: Neuromuscular Diseases:
Exondys 51d, Golodirsen, Deflazacort, Botulinum
Toxin
Specialty Drugs: Retinal Diseases: Luxturna
Specialty Drugs: Seizure Management: Epidiolex
Specialty Drugs: SMA: Spinraza, Zolgensma
OTHER:
Comments
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

SAR Fax Cover Sheet 06.2020 (Department of Health Care Services)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document