Reminder: New Proprietary Forms Now Available
New versions of Medi-Cal and Child Health and Disability Prevention (CHDP) proprietary forms are available from Medi-Cal. Providers are strongly encouraged to start placing orders for the updated proprietary forms as soon as possible in preparation for full implementation of the National Provider Identifier (NPI).
The old versions of the proprietary forms may still be used during the dual use Provider Identifier period, which has been extended beyond the original November 26, 2007 cutoff date, and will continue until further notice. When the supply of old forms runs out, providers may begin using the new forms. Only the Medi-Cal or CHDP provider number is required on the old or new forms during the extended dual use Provider Identifier period.
The following list identifies the proprietary forms that have been revised to accommodate use of the 10-digit NPI.
| Form Number | Form Name |
| 18-1 | Request for Extension of Stay in Hospital |
| 18-1C | Request for Extension of Stay in Hospital (Pin-Fed) |
| 18-2 | Request for Extension of Stay in Hospital (Fax) |
| 18-3 | Request for Mental Health Stay in Hospital |
| 20-1 | Long Term Care Treatment Authorization Request |
| 20-1CZ | Long Term Care Treatment Authorization Request (Pin-Fed) |
| 25-1 | Payment Request for Long Term Care |
| 25-1CZ | Payment Request for Long Term Care (Pin-Fed) |
| 30-1 | Pharmacy Claim Form |
| 30-1CZ | Pharmacy Claim Form (Pin-Fed) |
| 30-4 | Compound Drug Pharmacy Claim Form |
| 30-4CZ | Compound Drug Pharmacy Claim Form (Pin-Fed) |
| 50-1 | Treatment Authorization Request |
| 50-1C | Treatment Authorization Request (Pin-Fed) |
| 50-2 | Treatment Authorization Request (Fax) |
| 50-2C | Treatment Authorization Request (Pin-Fed/Fax) |
| 50-3 | Treatment Authorization Request (Vision Care) |
| 55-1 | Medi-Cal Managed Care Authorization Form (Discharge Planning Option) |
| 60-1 | Claims Inquiry Form |
| 60-1C | Claims Inquiry Form (Pin-Fed) |
| 90-1 | Appeal Form |
| PM 160 | CHDP Assessment Confidential Screening/Billing Report |
| PM 160INF | CHDP Assessment Confidential Screening/Billing Report (Information Only) |
| TAR 3 Form | Treatment Authorization Request Attachment Form |