Forms and resources for patients (79)
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1 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
11–14 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
12 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
15 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
15 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
18 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
2 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
2 week well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
24 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
3 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
30 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
4 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
4 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
5 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
6 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
6 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
7–10 year well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
9 month well child check
Download and fill out this form when you are bringing your child in for their regularly scheduled well child check.
Acute illness pediatric form
This is the form you need if your child is experiencing symptoms of an acute illness requiring medical attention.
ADHD pediatric form
Use this form if your child is being evaluated for ADHD or has already been diagnosed and is receiving treatment.
Advance beneficiary notice of noncoverage
Form for patient to accept responsibility in case Medicare provider payments do not fully cover expected amounts to Optum Specialty Pharmacy. Please complete and return the form to the requesting department.
Advance beneficiary notice of noncoverage (ABN) Spanish
Form for patient to accept responsibility in case Medicare provider payments do not fully cover expected amounts to Optum Specialty Pharmacy. Please complete and return the form to the requesting department.
Advance cost estimate notice
This notice explains our policy to provide a good faith estimate of expected charges prior to receiving services, for patients that might be uninsured or self-pay.
Alternative access standards
Learn more about alternative access standards for Medi-Cal members.