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The form also gathers symptom, impairment, medication, motivation, and request-reason checklists, plus authorization and release-of-information instructions for up to one year.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/pcp-referral-form-with-member-consent-carelon-behavioral-health-san-francisco-health-plan/288444/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/pcp-referral-form-with-member-consent-carelon-behavioral-health-san-francisco-health-plan/288444.png","ImageObject",442,249,{"name":42,"@type":43},"WPS_1786070896","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-22","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":33},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What information does the PCP Referral Form request about the member?","Question",{"text":62,"@type":63},"It asks for referral date, member name, Medi-Cal CIN ID, DOB, preferred language, phone number(s), and member address.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"How does the form handle consent for minors aged 12 and older?",{"text":67,"@type":63},"It includes a question on whether the minor has capacity to give consent to services, with space to explain if the answer is no.",{"name":69,"@type":60,"acceptedAnswer":70},"How is release of information handled in this form?",{"text":71,"@type":63},"The form states that completing it authorizes Carelon Behavioral Health to disclose health care information to identified individuals for up to one year, and it includes sections for who the information is released to.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},288444,1789633491,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":33,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":79,"read_time":22},549768072016,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Carelon Behavioral Health / San Francisco Health Plan Primary Care Provider (PCP) Referral Form  \nReferral Date:  Member Name:  Medi-Cal CIN ID\\#:  DOB:   Parent/Guardian Name:  Preferred Language:   Phone:   (home);   (parent/guardian’s cell);   (member’s cell) Member address:   Does the minor 12 and older have capacity to give consent to services? ☐ Yes ☐ No If no, please explain   Best day/time to reach the member:   Best day and time to reach the parent/guardian:    \nPCP Clinic/Agency:   Name of PCP:   PCP Phone \\#:    \nTo receive a confirmation of this referral's outcome, please check the box below noting preferred method and contact details:  \n☐ Email address:   ☐ Fax Number:  ☐ Please check to confirm member eligibility was verified  \nPCP Request (one request per referral form)  \nPCP Decision Support: To obtain a mental health educational conversation with a Carelon Behavioral Health psychiatrist related to psychiatric diagnoses/medications. Contact the National Peer Advisor line: Office Hours: 6am-5pm PST Monday – Friday Please call phone number: 877-241-5575   \n☐Referral for Outpatient Behavioral Health Services: Refer members for therapy or medication management via Carelon Behavioral Health’s network of providers when their needs are outside the PCP scope of practice. Carelon Behavioral Health can coordinate member care with county mental [health.](health. Fax: 877.321.1787 OR secure email: Medi-Cal.Referral@carelon.com)[ Fax:](health. Fax: 877.321.1787 OR secure email: Medi-Cal.Referral@carelon.com)[ 877.321.1787](health. Fax: 877.321.1787 OR secure email: Medi-Cal.Referral@carelon.com)[ OR secure email:](health. Fax: 877.321.1787 OR secure email: Medi-Cal.Referral@carelon.com)[ ](health. Fax: 877.321.1787 OR secure email: Medi-Cal.Referral@carelon.com)[Medi-Cal.Referral@carelon.com](health. Fax: 877.321.1787 OR secure email: Medi-Cal.Referral@carelon.com)  \n☐ Behavioral Health Treatment (BHT)/Applied Behavioral Analysis (ABA) Services: Specialty services for youth under 21 years old with established diagnosis of Autism Spectrum Disorder (ASD) or for whom BHT/ABA services are medially necessary. **Include documentation or progress note with physician order requesting ABA services.  \n[Fax:](Fax: 877.321.1776 OR secure email ASGCare.Managers@carelon.com)[ 8](Fax: 877.321.1776 OR secure email ASGCare.Managers@carelon.com)[77](Fax: 877.321.1776 OR secure email ASGCare.Managers@carelon.com)[.3](Fax: 877.321.1776 OR secure email ASGCare.Managers@carelon.com)[2](Fax: 877.321.1776 OR secure email ASGCare.Managers@carelon.com)[1.](Fax: 877.321.1776 OR secure email ASGCare.Managers@carelon.com)[1776](Fax: 877.321.1776 OR secure email ASGCare.Managers@carelon.com)[ OR secure email](Fax: 877.321.1776 OR secure email ASGCare.Managers@carelon.com)[ ](Fax: 877.321.1776 OR secure email ASGCare.Managers@carelon.com)[ASGCare.Managers](Fax: 877.321.1776 OR secure email ASGCare.Managers@carelon.com)[@carelon.com](Fax: 877.321.1776 OR secure email ASGCare.Managers@carelon.com)  \nRequest Reason (check all that apply):  \nSymptoms:  \n☐Depression ☐ Perinatal depression/anxiety  \n☐Poor self-care due to mental health ☐ Violence/Aggressive behavior  \n☐Psychosis (auditory/visual hallucinations, ☐ Psychological testing delusions) ☐ Neuropsychological testing  \n☐ PTSD/Trauma  \n☐ Chronic Pain  \n☐ Anxiety  \n☐ Adverse Childhood experiences (ACEs)  \n☐Substance use, please specify:  ☐Other BH symptoms:    \nImpairments:  \n☐Difficulties/Unable to complete ADLs ☐Difficulties maintaining relationships ☐ Legal ☐ CPS ☐Difficulties/Unable to go to work/school ☐Other:  Medications (list below or send medication list with this form, please include dosage):  \n_____________________________________________________________________________________________________________  \nMotivation for Services (check all that apply)  \n_____________________________________________________________________________________________________________  \n☐ Member (or guardian) has been i","cbCaiaKRKzmijtSr","https://ap.wps.com/l/cbCaiaKRKzmijtSr","pdf",1038294,"English","# PCP Referral Form\n## Referral Details\n## PCP Request and Decision Support\n## Referral Reason and Impairments\n## Motivation for Services\n## Authorization and Release of Information","[{\"question\":\"What information does the PCP Referral Form request about the member?\",\"answer\":\"It asks for referral date, member name, Medi-Cal CIN ID, DOB, preferred language, phone number(s), and member address.\"},{\"question\":\"How does the form handle consent for minors aged 12 and older?\",\"answer\":\"It includes a question on whether the minor has capacity to give consent to services, with space to explain if the answer is no.\"},{\"question\":\"How is release of information handled in this form?\",\"answer\":\"The form states that completing it authorizes Carelon Behavioral Health to disclose health care information to identified individuals for up to one year, and it includes sections for who the information is released to.\"}]","PCP Referral Form with Member Consent - Carelon Behavioral Health / San Francisco Health Plan | PDF"]