Forms for Providers
FIND A DOCUMENT OR FORM
|Summary of Care Form
A consent form patients sign allowing release of information to their PCP. PCPs are asked to provide any medical information that may relate to patient's behavioral health care, such as current and/or chronic medical conditions, current medications and dosages, sensitivities to medications and/or psychosocial stressors (e.g., loss of job, injuries, financial stress, parenting problems, etc.).
|Disease Management Form
Practitioners can refer their patients into WHA's Disease Management Programs, which include asthma, coronary artery disease and diabetes by submitting a completed Disease Management Referral Form. Completed forms should be mailed or faxed to Western Health Advantage, Attention: Health Promotion and Disease Management at 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833; Fax: (916) 568-0278
If you are filing a complaint or grievance on behalf of one of your patients, you may use this form to begin the grievance process. The completed GRIEVANCE FORM can either be mailed or faxed to Western Health Advantage, Attention: Grievances & Appeals, 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833; (916)563-2207.
|Privacy Complaint Form
As required by the Health Information Portability and Accountability Act (HIPAA) of 1996, you and your patients have the right to voice complaint(s) about WHA's privacy policies, procedures or actions. You may begin the complaint process by mailing the completed form to Western Health Advantage, Attention: Grievances & Appeals, 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833 or faxing it to (916) 563-2207.
|HMO Help Center Complaint Form
Your patients may complete and forward this form to the Department of Managed Health Care (DMHC), if they have already filed a complaint or grievance with their health plan. Mail or fax this form and any attachments to HMO Help Center, Department of Managed Health Care, Complaint Unit, 980 9th St., Suite 500, Sacramento, CA 95814; Fax: (916)255-5241.
Provider Dispute Resolution Request form
Provider disputes for denied, contested or adjusted claims issued by WHA should be filed with WHA
and not with the CMG. For PDR inquiries or filing instructions, you can call WHA at
(916) 563-2250 or
(888) 563-2250 (toll free) or
(888) 877-5378 (TTY/TDD).
Western Health Advantage
For your convenience, you can download and complete the attached standardized Provider Dispute Resolution Request form.