Forms & Resources

Health-Net Medicare Advantage Line of Business

  • NEMS-HN Specialist Roster (updated 5/31/19): Excel
  • Health Net MA Benefit and Authorization Grid (updated 5/31/19): Excel

SFHP Medi-Cal Line of Business

  • Specialist Roster (updated 7/2019): Excel
  • Ancillary Roster (updated 7/2019): Excel
  • NEMS-SFHP Benefit and Authorization Grid (updated 6/2019): Excel

General Forms

  • Treatment Authorization (TAR) Form (Revised 4/2014): Word | PDF
  • Provider Portal Access Request Form (Revised 3/2015): PDF

Claims Dispute Forms

  • Provider Dispute Resolution Request (PDRR) Form: Word | PDF
  • Provider Dispute Resolution Request (PDRR) Instructions: Word | PDF

Other Forms

  • None