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The L.A. Care forms category encompasses a wide range of essential documentation required for managing health coverage, social services, and medical authorizations within the L.A. Care Health Plan network and beyond. These forms are critical for ensuring that individuals receive appropriate care, whether they are enrolling in Medicare Part B, requesting specialized behavioral health treatments, or documenting life-changing events that impact insurance premiums. Accurate completion of these documents is vital for maintaining eligibility and ensuring that healthcare providers can deliver services without administrative delays.

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About L.A. Care forms

This collection is primarily used by patients, family members, and medical professionals who need to navigate the complexities of the healthcare system. For example, caregivers may need to submit authorization requests for Applied Behavioral Analysis (ABA) services, while employees might use certification forms like the WH-380-E to secure leave under the Family and Medical Leave Act (FMLA). From tax-related Medicare adjustments to child care assistance applications, these forms facilitate the necessary communication between individuals, government agencies, and insurance carriers. Tools like Instafill.ai use AI to fill these forms in under 30 seconds, handling your data accurately and securely so you can focus on care rather than paperwork.

Forms in This Category

	Form Name	Pages
1.	Form SSA-44, Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event	8
2.	Form WH-380-E, Certification of Health Care Provider	4
3.	Form 8959, Additional Medicare Tax	1
4.	Form CMS-460, Medicare Participation Agreement	3
5.	Form CMS-4040, Request for Enrollment in Medicare Part B	3
6.	Form 2441, Child and Dependent Care Expenses	2
7.	Form 4137, Social Security and Medicare Tax on Unreported Tip Income	2
8.	Form 8919, Uncollected Social Security and Medicare Tax	2
9.	Form CMS-1763, Request for Termination of Medicare Coverage	2
10.	Form CMS-855O, Medicare Enrollment Application	11
11.	Form WH-380-F, Certification of Health Care Provider	4
12.	Form W-10, Dependent Care Provider’s Identification	1
13.	Form CMS-40B, Application for Enrollment in Medicare Part B	4
14.	Form I-905, Application for Authorization to Issue Certification for Health Care Workers	3
15.	DHS-6696-ENG, Minnesota Health Care Programs Application (MNsure/DHS)	13
16.	Form WH-380-E, Certification of Health Care Provider for Employee’s Serious Health Condition under the Family and Medical Leave Act	4
17.	Form W-10 (Rev. October 2020), Dependent Care Provider’s Identification and Certification	1
18.	California Department of Social Services (CDSS) Community Care Licensing Child Care Forms Packet (LIC 9150, LIC 282, LIC 627, LIC 700, LIC 995A, CDPH 286, LIC 9227)	9
19.	State of Illinois Department of Human Services (IDHS) – Bureau of Child Care and Development Child Care Application (Form IL444-3455)	17
20.	Form CH-006: PA-BH-Res-PCS, Oregon Behavioral Health Support Program Plan of Care Authorization (Plan of Care Request for Behavioral Health Residential or Personal Care Services)	3
21.	State of Illinois Department of Children and Family Services Medical Report on an Adult in a Child Care Facility (CFS 602)	2
22.	Carer Payment and Carer Allowance – Medical Report (SA431) for a child under 16 years	13
23.	Pennsylvania Application for Subsidized Child Care (CY 868)	12
24.	Prior Authorization (PA) Request Form – Adult Palliative Care (Alameda Alliance for Health)	5
25.	Medicare Enrolment Application (Australia) – Enrol in Medicare, Re-enrol/Extend Eligibility, Enrol a Newborn, and Register for My Health Record	17
26.	Alameda Alliance for Health Prior Authorization (PA) Request Form – Adult Palliative Care	5
27.	California Department of Social Services (CDSS) Community Care Licensing Division — Administrative Organization (LIC 309)	2
28.	Health Assessment – Ontario Health atHome (Fixing Long-Term Care Act, 2021) (Form 4768-69E)	7
29.	Health Assessment - Ontario Health atHome (Fixing Long-Term Care Act, 2021) — Form 4768-69E	7
30.	Form 8919, Uncollected Social Security and Medicare Tax on Wages	1
31.	Request for Transfer of Records (Adelaide Health Care) – AHC-0013-05-PS (Version 2)	1
32.	Application for Access to Health Care Records (Nepean Blue Mountains Local Health District) – NBMA-431	2
33.	Applied Behavioral Analysis (ABA) Prior Authorization Request Form (Coordinated Care)	2
34.	L.A. Care Behavioral Health Treatment Applied Behavioral Analysis Authorization Request Form	1
35.	Medicaid Managed Care Applied Behavior Analysis — Authorization Request (Healthy Blue Louisiana, BLAPEC-1989-20)	4
36.	CareSource PASSE Applied Behavior Analysis (ABA) Prior Authorization Request Form	2
37.	Iowa Advance Directive: Durable Power of Attorney for Health Care and Declaration (Living Will)	10
38.	Form SSA-44, Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event	7
39.	Direct Rollover Request for Appalachian Regional Healthcare, Inc. Voluntary Plan	1
40.	John Hancock Independent Care Provider Service Reimbursement	2
41.	Molina Healthcare Prior Authorization Request Form	2
42.	UnitedHealthcare Prior Authorization Request Form	1
43.	Optum Rx / UnitedHealthcare Prior Authorization Request Form	1
44.	John Hancock Independent Care Provider Service Reimbursement	2
45.	Texas Standard Prior Authorization Request Form for Health Care Services	2
46.	Form OCFS-6001, Child Care Provider, Staff, Volunteer and Household Member Information	2
47.	CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners	25
48.	Form CMS-855R, Medicare Enrollment Application - Reassignment of Medicare Benefits	6
49.	Form T-3, Children with Special Health Care Needs (CSHCN) Services Program Application	9
50.	CMS-855R, Medicare Enrollment Application: Reassignment of Medicare Benefits	1
51.	CMS-855R, Medicare Enrollment Application: Reassignment of Medicare Benefits	1
52.	Form CMS-855O, Medicare Enrollment Application for Eligible Ordering, Certifying and Prescribing Physicians and Other Eligible Professionals	1
53.	Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers, CMS-855S	1
54.	Form CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners	1
55.	Form CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners	1
56.	42 CFR Part 489 - Provider Agreements and Supplier Approval (Centers for Medicare & Medicaid Services)	1
57.	Form CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners	1
58.	CMS-855B, Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers	1
59.	Medicare Enrollment Application, Clinics/Group Practices and Certain Other Suppliers, CMS-855B	1
60.	CMS-855A, Medicare Enrollment Application for Institutional Providers	1
61.	Form CMS-855A, Medicare Enrollment Application for Institutional Providers	1
62.	Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers, Form CMS-855S	1
63.	Medicare Enrollment Application - Enrollment for Eligible Ordering/Certifying Physicians and Other Eligible Professionals, Form CMS-855O	1
64.	Form CMS-588, Electronic Funds Transfer (EFT) Authorization Agreement for Accountable Care Organizations	1
65.	Form CMS-460, Medicare Participating Physician or Supplier Agreement	1
66.	Form CMS-460, Medicare Participating Physician or Supplier Agreement	1
67.	Medicare Enrollment Application - Medicare Diabetes Prevention Program (MDPP) Suppliers, Form CMS-20134	1
68.	Maryland Medical Care Program Provider Application	1
69.	Montana Healthcare Programs Provider Enrollment Application	1
70.	Montana Healthcare Programs Provider Enrollment Application	1
71.	UniCare Health Plan of West Virginia, Inc. Provider Application Form	1
72.	Form CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners	25
73.	Form T-3, Children with Special Health Care Needs (CSHCN) Services Program Application	9
74.	Healthcare Professional Credentialing Application	20
75.	Form CMS-40B, Request for Enrollment in Medicare Part B (Medical Insurance)	3

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How to Choose the Right Form

Navigating healthcare and insurance documentation can be complex, especially when dealing with a mix of federal, state, and provider-specific requirements. This guide helps you identify the correct paperwork for your specific situation.

Medicare Enrollment and Income Adjustments

If you are managing your Medicare coverage or associated costs, these forms are essential:

Medicare Enrollment: Use Form CMS-40B to apply for Part B if you already have Part A, or Form CMS-4040 for general enrollment. To end your coverage, use Form CMS-1763.
Income Adjustments: If a life-changing event (like retirement or marriage) has lowered your income, file Form SSA-44 to request a reduction in your Medicare premiums.
Tax Reporting: High-income earners should use Form 8959 for Additional Medicare Tax, while those with unreported tips need Form 4137.

Managed Care and Prior Authorizations

Healthcare providers and members often need approval before specific treatments can begin. This is common for L.A. Care and other managed care plans:

Behavioral Health (ABA): For Medi-Cal members seeking autism services, use the L.A. Care Behavioral Health Treatment Applied Behavioral Analysis Authorization Request Form (LA5480). Similar requests for other plans include the CareSource PASSE ABA Prior Authorization Request Form.
General Medical Services: Providers should use the Molina Healthcare Prior Authorization Request Form or the Texas Standard Prior Authorization Request Form depending on the patient's location and plan.
Palliative Care: Use the Alameda Alliance for Health Prior Authorization (PA) Request Form – Adult Palliative Care for specialized end-of-life or chronic illness support.

Child Care and Dependent Assistance

These forms are used for securing financial aid or tax benefits related to caregiving:

Tax Credits: Complete Form 2441 to claim child and dependent care expenses on your federal return. Ensure you have Form W-10 filled out by your care provider.
State Assistance: Families in specific regions should use the Pennsylvania Application for Subsidized Child Care (CY 868) or the Illinois Bureau of Child Care Application (Form IL444-3455).

Employment and Medical Leave

If you need to document a health condition for work-related leave under the Family and Medical Leave Act (FMLA), use:

Form WH-380-E for your own serious health condition.
Form WH-380-F when you are taking leave to care for a family member.

Form Comparison

Form	Purpose	Who Files It	When to Use
Form SSA-44, Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event	Request Medicare premium reduction after income change	Medicare beneficiaries	After a life-changing event reduces income
Form WH-380-E, Certification of Health Care Provider	Certify employee's serious health condition for FMLA	Health care provider on employee's behalf	When employee requests FMLA medical leave
Form 8959, Additional Medicare Tax	Report and calculate Additional Medicare Tax owed	High-income individuals	At tax filing when income exceeds Medicare threshold
Form CMS-460, Medicare Participation Agreement	Enroll as Medicare-participating provider for direct payment	Physicians and healthcare suppliers	When provider wants to accept Medicare Part B payments
Form CMS-4040, Request for Enrollment in Medicare Part B	Enroll in Medicare Part B supplementary insurance	Individuals eligible for Medicare	When applying for Medicare Part B coverage
Form CMS-40B, Application for Enrollment in Medicare Part B	Apply for Medicare Part B after missed enrollment period	Medicare Part A holders without Part B	During special or late enrollment periods
Form CMS-1763, Request for Termination of Medicare Coverage	Cancel Medicare Part A, Part B, or drug coverage	Medicare beneficiaries	When voluntarily ending Medicare coverage
Form CMS-855O, Medicare Enrollment Application	Enroll to order/certify items for Medicare beneficiaries	Eligible physicians and professionals	When seeking Medicare ordering/certifying privileges
L.A. Care Behavioral Health Treatment Applied Behavioral Analysis Authorization Request Form	Request prior authorization for ABA services	ABA providers for Medi-Cal members	Before scheduling ABA therapy services
Applied Behavioral Analysis (ABA) Prior Authorization Request Form (Coordinated Care)	Obtain approval for ABA therapy services	Providers submitting to Coordinated Care	Before initiating or continuing ABA treatment
CareSource PASSE Applied Behavior Analysis (ABA) Prior Authorization Request Form	Request pre-approval for ABA therapy for ASD members	Providers submitting to CareSource PASSE	Before delivering ABA services to members
Iowa Advance Directive: Durable Power of Attorney for Health Care and Declaration (Living Will)	Document healthcare decisions and appoint medical agent	Iowa residents planning for incapacity	When establishing end-of-life care preferences

Tips for L.A. Care forms

Ensure Provider Identifiers Match Official Records Exactly

When filling out enrollment or prior authorization forms, double-check that the National Provider Identifier (NPI) and Tax Identification Number (TIN) match your official registry. Inconsistencies between these numbers and the data on file with the insurer can lead to immediate claim denials or significant processing delays.

Attach Required Clinical Evidence for Faster Approval

Most behavioral health and medical leave forms require supplemental evidence, such as diagnostic reports, treatment plans, or lab results, to be submitted with the application. Failing to include these mandatory attachments often results in the form being returned as incomplete, which restarts your waiting period.

Coordinate Signatures from Multiple Parties Early

Forms for child care assistance and FMLA certifications often require signatures from both the applicant and a third party, such as a physician or care provider. Review the certification sections first to ensure you have enough time to obtain these professional endorsements before your submission deadline.

Use AI to Accelerate Form Completion

AI-powered tools like Instafill.ai can complete these complex healthcare and tax forms in under 30 seconds with high accuracy. This process ensures your sensitive medical and financial data stays secure while saving you hours of manual data entry across multiple related documents.

Verify Qualifying Life Event Details for Medicare

For Medicare income adjustments or special enrollments, ensure you have the specific dates and documentation for your qualifying life event, such as retirement or a change in employer coverage. Providing the exact date of the event is critical for the Social Security Administration to calculate your updated premium rates correctly.

Prioritize Digital Entry for Better Legibility

Handwritten forms are a leading cause of processing errors in insurance authorizations and government applications. Using a digital tool to type your information ensures that processors can read your ICD-10 codes and contact details clearly, significantly reducing the risk of administrative rejection.

Maintain Secure Copies of Dependent Care Records

For forms related to dependent care tax credits, keep a digital copy of the provider’s identification and your itemized receipts in a secure folder. While these forms are used for immediate credits, the IRS may request the original documentation years later to verify your eligibility for care expenses.

Frequently Asked Questions

What types of forms are included in the L.A. Care category?

This category includes a wide range of documents related to healthcare access, such as Medi-Cal prior authorization requests, Medicare enrollment applications, and behavioral health treatment forms. You will also find forms for family leave (FMLA) certifications, child care licensing, and tax documents related to Medicare premiums and dependent care expenses.

Who typically needs to fill out L.A. Care behavioral health forms?

These forms are usually completed by healthcare providers, such as Board Certified Behavior Analysts (BCBAs) or psychologists, on behalf of members seeking Applied Behavioral Analysis (ABA) services. They are required to demonstrate medical necessity and obtain approval from L.A. Care before specialized treatment can begin.

How do I know if I need a prior authorization form?

You generally need a prior authorization form if your insurance plan requires pre-approval for specific medical services, procedures, or medications before they are rendered. If you are an L.A. Care or Medi-Cal member, your doctor or specialist will often submit these forms to ensure the service is covered under your specific benefit plan.

Can I fill out L.A. Care forms using AI?

Yes, you can use AI tools like Instafill.ai to fill out L.A. Care and other medical forms in under 30 seconds. The AI accurately extracts data from your source documents and places it directly into the required fields, which helps reduce the risk of manual entry errors on complex medical paperwork.

Where should I submit my completed L.A. Care or Medicare forms?

Submission instructions vary depending on the specific document; for example, Medicare enrollment forms are typically sent to the Social Security Administration, while L.A. Care authorization forms are faxed or uploaded to their specialized departments. Always check the 'Where to File' section on the form or the organization's official website for the correct mailing address or provider portal.

What is the purpose of the Medicare Life-Changing Event form (SSA-44)?

This form is used by beneficiaries to request a reduction in their Medicare Part B or Part D premiums if their income has significantly decreased due to a major event. Common reasons for filing include retirement, marriage, divorce, or the death of a spouse, all of which may lower your Income-Related Monthly Adjustment Amount (IRMAA).

Are there specific forms for child care providers in this category?

Yes, this category includes several California Department of Social Services (CDSS) forms used for the licensing and administrative organization of child care facilities. There are also forms for parents to apply for subsidized child care and for providers to certify their identification for tax purposes.

How long does it take to fill these forms online?

While manually filling out complex medical or tax forms can take 15 to 30 minutes, using an AI-powered tool like Instafill.ai can complete the process in less than 30 seconds. The technology automates the data entry process by extracting information from your existing files, making it much faster to prepare documents for submission.

What should I do if a form requires a physician's signature?

For forms like the FMLA Certification or medical reports, you must have a licensed healthcare professional complete the clinical sections and provide their signature. Once they have completed their portion, you can scan the document or use a digital platform to finalize and submit it to your employer or insurance carrier.

Why are there tax forms like Form 8919 in a health care category?

Certain tax forms are included because they relate directly to Social Security and Medicare taxes. For example, Form 8919 is used by workers to report their share of uncollected Medicare taxes, ensuring their earnings are correctly credited to their Social Security record for future healthcare and retirement benefits.

Glossary

Medi-Cal: California's Medicaid program that provides free or low-cost health coverage for children and adults with limited income and resources.
Prior Authorization (PA): A requirement from a health insurance plan that your doctor must obtain approval before you receive certain medical services, procedures, or medications.
Medicare Part B: The portion of Medicare that covers medically necessary services like doctor visits, outpatient care, and medical supplies.
Applied Behavioral Analysis (ABA): A type of therapy often used for individuals with Autism Spectrum Disorder to improve specific behaviors and social skills.
NPI (National Provider Identifier): A unique 10-digit identification number issued to healthcare providers in the United States by the federal government for billing and tracking.
IRMAA (Income-Related Monthly Adjustment Amount): An extra charge added to Medicare Part B or Part D premiums if a beneficiary's income exceeds a certain threshold.
CPT/HCPCS Codes: Standardized alphanumeric codes used by healthcare providers to identify specific medical, surgical, and diagnostic services for insurance reimbursement.
CMS (Centers for Medicare & Medicaid Services): The federal agency that administers the Medicare program and works with state governments to manage Medicaid and the Children's Health Insurance Program.

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