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If prior authorization requests are needed for multiple members, submit one form per member.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What additional documentation is required to support a prior authorization request?",{"text":68,"@type":64},"Provide additional clinical information or medical documentation that supports initial or ongoing therapy or increased dose, such as symptoms and lab results with dates when needed to establish diagnosis or evaluate response. Peer-reviewed journal articles may be required for off-label use or dosing exceeding FDA-approved limits.",{"name":70,"@type":61,"acceptedAnswer":71},"What information must the provider attest on the form?",{"text":72,"@type":64},"The provider attests that the information provided is true and accurate to the best of their knowledge and understands Medi-Cal Rx or its designees may perform routine audits and request medical information needed to verify accuracy.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283674,1790178291,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":33,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":26},962084931830,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","State of California – Health and Human Services Agency Department of Health Care Services  \nMedi-Cal Rx Prior Authorization Request  \nInstructions: Fill out all applicable sections on every page completely and legibly. Attach any additional documentation that is important for the review, such as chart notes or lab data, to support the prior authorization (PA) request.  \nFailure to submit the requested information may result in a returned PA request.  \nSubmit one PA request per member. If you need to submit PA requests for multiple members, you must submit one form per member.  \nThis form contains Protected Health Information (PHI) that is protected under HIPAA.  \nMember Information  \nLast Name:   First Name:   Date of Birth:   Phone Number:   Member ID Number:   \nMember Address:   City:   State:   ZIP Code:    \nMale Female Height (in/cm):   Weight (lb/kg):    \nPregnant: Yes No  \nAllergies:   Member Residence: Home Skilled Nursing Facility (SNF)  \nNursing Facility (Long Term Care [LTC] Facility or Intermediate Care Facility) Other Location (not specified)  \nPrescriber Information  \nLast Name:   First Name:   Prescriber National Provider Identifier (NPI) Number:   Prescriber Specialty:   Prescriber Phone Number:   Prescriber Fax Number:   Prescriber Address:   City:   State:   ZIP Code:    \nRequestor Information (if different than Prescriber)  \nRequestor (Business Name or First/Last):   Requestor NPI Number:   Requestor Phone Number:   Requestor Fax Number:   Requestor Address:   City:   State:   ZIP Code:    \nDHCS 6560 (Revised 08/2026) Page 1 of 4  \nState of California – Health and Human Services Agency Department of Health Care Services  \nMember Last Name:   Member First Name:    \nMedication and Dispensing Information  \nMedication Name:    \nIs this request for a drug with a dispense as written (DAW) code of DAW 1? Yes No  \nIs this request for drug coverage for emergency services? Yes No  \nStrength:   Formulation:   Directions for Use:   Length of Therapy/Number of Refills:   Quantity:   Will this medication be administered in the provider’s office, clinic, or hospital? Yes No  \nNew Request Renewal Request Appeal Request for a PA Denied in the Past 180 days  \nIf Renewal:  \nDate Therapy Initiated:   Duration of Therapy (specific dates):    \nHow did the patient receive the medication?  \nPaid Under Insurance  \nInsurance Name:   PA Number (if known):   Other:    \n1. Product Use History  \nHas the patient tried any other medications for this condition? Yes No  \nIf Yes , complete the following fields:  \nMedication/Therapy 1  \nDrug Name and Dosage:   Duration of Therapy (specific dates):   Response/Reason for Failure/Allergy:  \nMedication/Therapy 2  \nDrug Name and Dosage:   Duration of Therapy (specific dates):   Response/Reason for Failure/Allergy:  \nDHCS 6560 (Revised 08/2026) Page 2 of 4  \nState of California – Health and Human Services Agency Department of Health Care Services  \nMember Last Name:   Member First Name:    \nMedication/Therapy 3  \nDrug Name and Dosage:   Duration of Therapy (specific dates):   Response/Reason for Failure/Allergy:  \n2. Diagnosis and ICD-10-CM  \nList the diagnoses and the associated International Classification of Diseases – 10th Revision, Clinical Modification (ICD-10-CM) diagnosis code(s):  \nDiagnosis  ICD-10-CM Diagnosis Code  \n3. Required Clinical Information  \nProvide any additional clinical information or medical documentation to support a PA, such as symptoms, lab results with dates, and/or justification for initial or ongoing therapy or increased dose, and if patient has any contraindications for the preferred drug(s) . Lab results with dates must be provided if needed to establish diagnosis or evaluate response. Provide any additional clinical information or comments pertinent to this request for coverage, including information related to exigent circumstances, or required under state and federal laws.  \nNote: If the request is for an off-label use of the medication or if it exceeds dosage limi","cbCaidBPaBOuby5l","https://ap.wps.com/l/cbCaidBPaBOuby5l","pdf",799344,"English","# Member Information\n# Prescriber Information\n# Requestor Information\n# Medication and Dispensing Information\n# Product Use History\n# Diagnosis and ICD-10-CM\n# Required Clinical Information\n# Attestation and Confidentiality Notice","[{\"question\":\"How many prior authorization requests should be submitted per member?\",\"answer\":\"Submit one prior authorization request per member. If prior authorization requests are needed for multiple members, submit one form per member.\"},{\"question\":\"What additional documentation is required to support a prior authorization request?\",\"answer\":\"Provide additional clinical information or medical documentation that supports initial or ongoing therapy or increased dose, such as symptoms and lab results with dates when needed to establish diagnosis or evaluate response. Peer-reviewed journal articles may be required for off-label use or dosing exceeding FDA-approved limits.\"},{\"question\":\"What information must the provider attest on the form?\",\"answer\":\"The provider attests that the information provided is true and accurate to the best of their knowledge and understands Medi-Cal Rx or its designees may perform routine audits and request medical information needed to verify accuracy.\"}]","Medi-Cal Rx Prior Authorization Request Form | PDF",1789616635]