Access the latest IEHP Medi-Cal Physician Administered Drug (PAD) Prior Authorization criteria and list.

Mar 7, 2019 · Criteria utilized in making this decision is available upon request by calling IEHP (866) 725-4347. UPON ACCEPTANCE OF REFERRAL AND TREATMENT OF THE …

Complete Service Request Form in its entirety. Attach clinical notes, signed MD orders, and supporting documents. Fax Service Request Form and supporting all documents to (909) …

Apr 3, 2023 · Complete Service Request Form in its entirety. Attach clinical notes, signed MD orders, and supporting documents. Please Note: request will be delayed if any required …

Authorization for such disclosure is obtained from me or unless such disclosure is specifically required or permitted by law. I am aware that I may stop (revoke) this appointment at any time …

Authorization Information section. Please Enter a valid IEHP ID, authorization number, select a Behavioral Health Service Provider and select a Request for Additional Services option.

Please enter the access code that you received in your email or letter.

Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to …

For questions, comments, or password information, call IEHP's Provider Relations team at (909) 890-2054 or e-mail us at [email protected].

HIPAA, federal regulations and California law require that this Authorization be completed to authorize Inland Empire Health Plan (IEHP) to use and disclose Protected Health Information …