Community Health Worker (CHW)
Supervising Provider Service Recommendation Form
To request Community Health Worker (CHW) services covered by CenCal Health, a completed recommendation form is required to be submitted for a CHW to be able to render services. This recommendation form can be submitted by fax (805) 681-3071 or sent via secure link at
https://gateway.cencalhealth.org/form/hs

Important reminders:
• 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.

*FIELDS ARE MANDATORY


PATIENT INFORMATION:
CHW SUPERVISING PROVIDER (CHW ORGANIZATION) INFORMATION:
CHW Supervise Provider *:
Name *:
NPI *:
RECOMMENDING PROVIDER INFORMATION:
Name *:
Title *:
# CHECK AT LEAST ONE (1) OF THE BOXES IN THIS SECTION.
FOR CHW VIOLENCE PREVENTION SERVICES (CHECK IF APPLICABLE):
FOR ASTHMA EDUCATION AND IN-HOME ENVIRONMENTAL TRIGGER ASSESSMENTS (CHECK IF APPLICABLE):