https://gateway.cencalhealth.org/form/hs
• This form is not a request for authorization. Use the Authorization Request Form for Additional Units to request authorization for CHW services beyond 12 units of service (or 8 units for Asthma Prevention) in a calendar year.
• Members currently enrolled in CenCal Health’s Enhanced Care Management (ECM) benefit are not eligible to receive CHW services.
• A CHW Supervising Provider(s) is required to retain a copy of this recommendation form in the member file.