Forms, Downloads, & Fax Numbers
Please see the links below to obtain the appropriate form to submit to CenCal Health.
Please complete the form, print it out and fax it to the number shown on the top of the form. This form must be approved by CenCal Health prior to the member receiving the requested item.
The Medical Request Form (MRF), must be printed out and faxed to CenCal Health by the prescriber for any pharmaceutical or medical supply that requires a Prior Authorization or is not on CenCal Health’s formulary.
Authorizations are not a guarantee of payment. The provider is responsible for verifying a member’s eligibility on the dates of service.
Please ensure patient’s eligibility is current prior to rendering service.
CenCal Health Drug Formulary & Medical Request Form (MRF)
Forms & Downloads
CenCal Health Medical Request Form (MRF) – Fax: (805) 685-7781
Universal Prior Authorization Form (#61-211) – Fax: (805) 685-7781
Synagis Enrollment Form-Fax: (805) 685-7781
Hepatitis C Medication Request Form – Fax: (805) 685-7781
P & T Formulary Additions – (Restricted) – Fax: (805) 964-0367