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Carelon Behavioral Health of California, Inc./Central California Alliance for Health
Primary Care Provider (PCP) Referral Form
Referral Date:______________ Member Name:____________________________________________ Medi-Cal CIN ID#:_______________________________
DOB: ____________________ Parent/Guardian Name:______________________________________ Preferred Language: ____________________________
Phone: ____________________ (home); ________________________________ (parent/guardian’s cell); ______________________________ (member’s cell)
Member address: ___________________________________________________________________________________________________________________
Does the minor 12 and older have capacity to give consent to services? ☐ Yes ☐ No If no, please explain _________________________________________
Best day/time to reach the member: ________________________________ Best day and time to reach the parent/guardian: _____________________
PCP Clinic/Agency: _____________________________ Name of PCP: __________________________________ PCP Phone #: _________________________
To receive a confirmation of this referral's outcome, please check the box below noting preferred method and contact details:
☐ Email address: __________________________________
☐ Fax Number: __________________________________
☐ Please check to confirm member eligibility was verified
PCP Request (one request per referral form)
PCP Decision Support: To obtain a mental health educational conversation with a Carelon Behavioral Health psychiatrist related
to psychiatric diagnoses/medications. Contact the National Peer Advisor line: Office Hours: 6am-5pm PST Monday – Friday
Please call phone number: 877-241-5575
☐Referral for Outpatient Behavioral Health Services: Refer members for therapy or medication management via Carelon
Behavioral Health’s network of providers when their needs are outside the PCP scope of practice. Carelon Behavioral Health can
coordinate member care with county mental health. Fax: 877.321.1787 OR secure email:
☐Behavioral Health Treatment (BHT)/Applied Behavioral Analysis (ABA) Services: Specialty services for youth under 21 years
old with established diagnosis of Autism Spectrum Disorder (ASD) or for whom BHT/ABA services are medically necessary.
**Include documentation, Progress Note, or Diagnostic Evaluation Form with physician order requesting ABA services. Fax:
877.321.1776 OR secure email: [email protected]
☐Referral for Psychological or Neuropsychological testing: Refer members to psychological/neuropsychological testing via
Carelon Behavioral Health’s network of providers when their needs are outside the PCP scope of practice. Carelon Behavioral Health
can coordinate member care with county mental health. Fax: 877.321.1787 OR secure email:
Request Reason (check all that apply):
☐Depression ☐ Perinatal depression/anxiety
☐Poor self-care due to mental health ☐ Violence/Aggressive behavior
☐Psychosis (auditory/visual hallucinations, ☐ Psychological testing
☐ PTSD/Trauma
☐ Chronic Pain
☐ Anxiety
☐ Development and/or Autism
delusional) ☐ Neuropsychological testing
☐ Adverse Childhood experiences (ACEs)
☐Substance use, please specify: ________________________________________________________________________
☐Other BH symptoms: ________________________________________________________________________
Impairments:
☐Difficulties/Unable to complete ADLs ☐Difficulties maintaining relationships ☐Legal ☐CPS
☐Difficulties/Unable to go to work/school ☐Other:___________________________________
Medications (list below or send medication list with this form):
Motivation for Services (check all that apply)
☐ Member (or guardian) has been informed for referral to Carelon Behavioral Health
☐ Member wants services for self (or dependent)
☐ Member is unsure or ambivalent about services for self (or dependent)
☐ If applicable, Patient has completed a PHQ-2/PHQ-9, Score ___________
For members 12 and older, in certain situations under privacy law AB1184 a written ROI may be required to share sensitive information with anyone
including parents and guardians. If possible, please send this referral form along with a completed release of information for anyone who may be
involved in the member’s care.
.
Revised: 12/28/23
Authorization for Carelon Behavioral Health of
California to Release Confidential Information
Important: By completing all sections of this form, you allow Carelon Behavioral Health of California
to disclose health care information to the individuals you identify for up to one year. You may allow
Carelon Behavioral Health of California to share health care information with your family, providers,
legal representative, or anyone you wish to have access. Please fill in all sections as incomplete
forms may be returned.
Please note: It is also important for your doctor to have access to your medical information
to ensure you receive the best care possible, including any follow-up care that may be
needed. To allow Carelon Behavioral Health of California the ability to send your health
care information to your doctor, complete and sign this form. We will only send information
that pertains to your care.
If your request involves alcohol or substance use information, please pay attention
to the special instructions in the applicable sections.
SECTION 1: WHOSE HEALTH CARE INFORMATION IS TO BE RELEASED?
(Member Name) authorize Carelon
Behavioral Health of California (or any Carelon Behavioral Health subsidiary holding my information)
to disclose my health care information as described below.
Additional Member Identifying Information Member ID#:
Phone Number: Name of Health Plan:
SECTION 2: WHO IS TO RECEIVE THIS HEALTH CARE INFORMATION?
Print the Name(s) of person, provider or entity who will be receiving your information and contact
information (if known):
Phone number of who will be receiving your information:
I,
DOB:
Is it ok to include information from past, present, and/or future treating provider(s)?:
Yes
No
Page 1 of 3 Learn more at: carelonbehavioralhealthca.com Updated 12/23
Authorization for Carelon Behavioral Health of
California to Release Confidential Information
SECTION 3: WHY SHOULD THIS HEALTH CARE INFORMATION BE RELEASED?
Reason (“At my request” is an acceptable response):
Specify, if possible:
☐Care Coordination/Management
☐Claim Assistance
☐Quality of Care Review
☐Other (Please explain reason):
SECTION 4: WHAT HEALTH CARE INFORMATION MAY BE RELEASED?
BY INITIALING the items on the following page, you authorize Carelon Behavioral Health of
California to release specific types of information to the party identified in Section 2 above:
Mental health information and/or records (INITIALS REQUIRED)
Alcohol or substance use information and/or records (INITIALS REQUIRED)
Optional:
HIV/ Claims AIDS related information and/or records (INITIALS REQUIRED)
Claims Info
Denials/Appeals Info
Authorizations
Explanation of benefit letters
Clinical notes
Other health information, please specify (INITIALS REQUIRED):
Special instructions, if any (you may specify provider, date span, service type, etc.):
Page 2 of 3 Learn more at: carelonbehavioralhealthca.com Updated 12/23
Authorization for Carelon Behavioral Health of
California to Release Confidential Information
SECTION 5: HOW LONG SHOULD THIS AUTHORIZATION LAST?
This authorization shall be in force and effect for one year or until I revoke it, in the manner described
below or until (insert expiration date or event)
shorter).
SECTION 6: WHAT ARE MY RIGHTS?
•
You have a right to request a copy of this form and to request a copy of the information that is being
disclosed.
•
You do not have to sign this authorization and your refusal will not affect your benefits unless
this authorization is necessary to determine your benefits.
•
The information disclosed by this authorization may be at risk for re-disclosure by the recipient
and if that happens, it might no longer be protected by federal privacy laws.
•
You have a right to revoke this authorization at any time. But if you revoke this authorization,
the revocation will not affect the disclosure of any information that Carelon Behavioral
Health of California has already sent to the recipient.
•
If you authorized release of alcohol or substance use information to a healthcare organization that
is not your treating provider, for the next two years, you have the right to find out who within that
organization actually saw your information. You should contact the organization directly for that
information.
Please note that if you have authorized the release of ONLY alcohol or substance use treatment
records, you may revoke this authorization verbally. Revocation involving all other types of health care
records must be in writing.
(whichever is
Signature of the Member or the Member’s Legally Authorized Representative* Date
Print Name
* NOTE: If you are signing as the individual’s Legally Authorized Representative, attach a copy
of the appropriate legal document(s) granting you the authority to do so. Examples would be a
health care power of attorney, a court order, guardianship papers, etc. A financial or business
power of attorney is NOT sufficient.
Please contact the phone number for behavioral health, mental health, or substance
use services on your medical ID card with any questions or to determine where to
mail or fax your request.
Page 3 of 3 Learn more at: carelonbehavioralhealthca.com Updated 12/23
