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L.A. Care forms cover a broad range of health care and benefits-related documentation, from prior authorization requests for specialized services like Applied Behavioral Analysis (ABA) to Medicare enrollment applications, FMLA medical certifications, and Medi-Cal eligibility paperwork. Whether you're a provider seeking approval for behavioral health treatment, a patient managing Medicare coverage, or a caregiver navigating public health programs, this category brings together the forms most commonly needed when working within or alongside L.A. Care's health plan network.
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About L.A. Care forms
These forms are used by a wide range of people — Medi-Cal members and their families, licensed behavioral health providers, physicians, care coordinators, and individuals managing their own Medicare or dependent care benefits. Some forms, like the L.A. Care ABA Authorization Request (LA5480), are specific to L.A. Care's programs, while others — such as CMS enrollment forms, IRS tax forms related to Medicare, and FMLA certifications — are federal or state documents that frequently come up in the context of health care coverage and benefits.
Because many of these forms require precise clinical, demographic, and insurance details, accuracy matters — incomplete or incorrect submissions can delay authorizations or cause coverage gaps. Tools like Instafill.ai use AI to fill these forms in under 30 seconds, handling the data accurately and securely so you can spend less time on paperwork and more time on care.
Forms in This Category
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How to Choose the Right Form
With 37 forms spanning Medicare, behavioral health, child care, FMLA, and more, this collection covers a wide range of health and social services needs. Use the groups below to zero in on the right form quickly.
L.A. Care & Behavioral Health Authorization
If you're a provider or member seeking approval for ABA (Applied Behavioral Analysis) services, start here:
- L.A. Care Behavioral Health Treatment ABA Authorization Request Form (LA5480) — the primary form for L.A. Care Medi-Cal members needing ABA services
- CareSource PASSE ABA Prior Authorization Request Form and Healthy Blue Louisiana ABA Authorization Request (BLAPEC-1989-20) — for members in other Medicaid managed care plans
- Coordinated Care ABA Prior Authorization Request Form — for Coordinated Care plan members
- Prior Authorization (PA) Request Form – Adult Palliative Care (Alameda Alliance for Health) — if you need PA for palliative care, not ABA
Medicare Enrollment & Coverage
For enrolling in, adjusting, or ending Medicare coverage:
- Form CMS-40B and Form CMS-4040 — both handle Medicare Part B enrollment; CMS-40B is for those already on Part A, CMS-4040 is for general supplementary insurance enrollment
- Form CMS-460 — for healthcare providers joining Medicare as participating suppliers
- Form CMS-855O — for physicians who need to order or certify items for Medicare beneficiaries
- Form CMS-1763 — to terminate Medicare Part A, Part B, or immunosuppressive drug coverage
- Form SSA-44 — to request a premium reduction after a life-changing income event
Tax Forms Related to Medicare & Dependent Care
- Form 8959 — report Additional Medicare Tax if you have high income
- Form 8919 / Form 4137 — report uncollected or unreported Social Security and Medicare taxes
- Form 2441 and Form W-10 — claim child and dependent care tax credits and document provider information
FMLA Medical Certification
- Form WH-380-E — for an employee's own serious health condition
- Form WH-380-F — for a family member's serious health condition
Child Care Assistance Applications
Need help paying for child care? Choose by state:
- Form IL444-3455 — Illinois subsidized child care
- Pennsylvania CY 868 — Pennsylvania subsidized child care
- DHS-6696-ENG — Minnesota health coverage (MNsure/DHS)
Medical Records & Advance Directives
- NBMA-431 or Adelaide Health Care AHC-0013-05-PS — request access to or transfer of health records
- Iowa Advance Directive — document healthcare wishes and designate a decision-maker
Still unsure? Match your plan name, state, or service type to the form descriptions above.
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
L.A. Care forms — especially prior authorization and ABA requests — require member Medi-Cal numbers, provider NPIs, and TINs to match exactly what is on file with L.A. Care. Even a single transposed digit can cause a denial or delay, so double-check all identifiers against your insurance card or provider enrollment records before submitting.
Most L.A. Care authorization forms, including ABA and behavioral health requests, explicitly require supporting clinical documentation such as DSM-V/ICD-10 diagnoses, treatment plans, and functional assessments. Submitting the form without these attachments is one of the most common reasons requests are returned or delayed — treat supporting documents as mandatory, not optional.
For L.A. Care behavioral health and ABA services, authorization must be approved before services are scheduled or rendered. Providing services prior to approval can result in non-payment, so confirm your authorization number in writing before booking any appointments or beginning treatment.
If you're managing several L.A. Care forms at once — such as an ABA authorization alongside Medicare enrollment or FMLA certification paperwork — AI-powered tools like Instafill.ai can complete each form accurately in under 30 seconds. Your data stays secure throughout the process, making it a practical time-saver for providers and families juggling multiple submissions.
Many authorization forms ask you to identify whether your request is initial, a recertification, a change-in-condition, or retroactive. Selecting the wrong request type is a common mistake that can send your form to the wrong review queue. Read the options carefully and check the appropriate box before filling in any other details.
Whether you're submitting a prior authorization, a Medicare enrollment application, or an FMLA certification, always save a dated copy of the completed form and any attachments. L.A. Care and partner agencies may request resubmission or clarification, and having your original on hand prevents you from starting over from scratch.
L.A. Care authorization forms and many related healthcare forms explicitly state that handwritten or illegible submissions may be returned without processing. Always type your responses directly into the form fields or use a fill-and-print tool to ensure every entry is clear, complete, and machine-readable.
Authorization approvals are contingent on the member being eligible for coverage at the time services are rendered — not just at the time of submission. Confirm current Medi-Cal or plan eligibility through L.A. Care's provider portal before investing time in completing and submitting any authorization or enrollment form.
Frequently Asked Questions
This category includes 37 forms covering a wide range of healthcare and benefits-related needs, such as Medicare enrollment and termination, FMLA medical certifications, ABA prior authorization requests, Medicaid managed care forms, child care assistance applications, advance directives, and tax forms related to Medicare and dependent care. Whether you are a patient, caregiver, or healthcare provider, you are likely to find a relevant form here.
These forms are used by a broad range of individuals and organizations, including Medicare beneficiaries, employees seeking FMLA leave, healthcare providers applying for Medicare enrollment or requesting prior authorization, families applying for child care assistance, and individuals planning for future medical decisions. Some forms are also intended for licensed professionals such as physicians, BCBAs, and behavior analysts.
The right form depends on your specific situation. For example, if you need prior authorization for Applied Behavioral Analysis (ABA) services for a Medi-Cal member, you would use the L.A. Care Behavioral Health Treatment ABA Authorization Request Form (LA5480). If you are a Medicare beneficiary who has experienced a life-changing event affecting your income, you would use Form SSA-44. Reviewing each form's description on this page will help you identify the correct one for your needs.
The L.A. Care ABA Authorization Request Form (LA5480) is used to obtain prior authorization for Applied Behavioral Analysis services for eligible Medi-Cal members, including Comprehensive Diagnostic Evaluations, Direct ABA Services, Case Supervision, and Parent Education Training. Services cannot be scheduled until authorization is granted, so submitting a complete and accurate form is essential to avoid delays.
Yes, this category includes forms for both patients and healthcare providers. Providers may need forms such as CMS-460 (Medicare Participation Agreement), CMS-855O (Medicare Enrollment Application), or prior authorization request forms for ABA and palliative care services. Patients and beneficiaries, on the other hand, may need forms related to Medicare enrollment, FMLA certification, or advance directives.
Submission destinations vary depending on the form. Medicare-related forms are generally submitted to the Social Security Administration or Centers for Medicare & Medicaid Services. Prior authorization forms like the L.A. Care ABA Authorization Request are submitted directly to L.A. Care's relevant department. FMLA certification forms are returned to the employee to provide to their employer. Always check the specific instructions on each form or contact the relevant agency for submission guidance.
Several forms in this category are time-sensitive. For example, FMLA certification forms (WH-380-E and WH-380-F) typically must be returned within a timeframe set by the employer, and Medicare enrollment forms may have specific enrollment period windows. Prior authorization forms for ABA services must be submitted and approved before services begin. It is important to review the instructions for each specific form and contact the relevant agency to confirm any applicable deadlines.
Yes, AI-powered tools like Instafill.ai can fill out forms in this category in under 30 seconds by accurately extracting and placing data from your source documents. This is especially useful for complex forms like prior authorization requests or Medicare enrollment applications, where accuracy and completeness are critical to avoiding delays or denials.
Manually completing these forms can take anywhere from a few minutes to over an hour, depending on the complexity of the form and how much clinical or personal information is required. Using AI tools like Instafill.ai, the same forms can be filled out in under 30 seconds by automatically extracting relevant data from existing documents and placing it accurately into the correct fields.
Yes, several forms in this category address child and dependent care needs. These include Form 2441 (Child and Dependent Care Expenses) and Form W-10 (Dependent Care Provider's Identification) for tax purposes, as well as state-specific child care assistance applications for Illinois and Pennsylvania, and a California child care licensing forms packet. These forms help families access financial assistance and ensure compliance with licensing requirements.
Some forms in this category may be available only as non-fillable PDFs. In these cases, services like Instafill.ai can convert non-fillable PDF versions into interactive fillable forms, making it easier to complete them accurately online without printing and handwriting. This can save significant time, especially for lengthy or complex forms.
Yes, the L.A. Care Behavioral Health Treatment ABA Authorization Request Form (LA5480) is specifically designed for L.A. Care Medi-Cal members and must be submitted to L.A. Care's BH ASD Program Department. Additionally, California-specific forms such as the CDSS Community Care Licensing forms packet and the LIC 309 Administrative Organization form are included in this category for providers operating in California.
Glossary
- Prior Authorization (PA)
- Approval that must be obtained from a health plan (like L.A. Care) before certain medical services, treatments, or medications are provided. Without prior authorization, the health plan may not cover the cost of the service.
- Medi-Cal
- California's Medicaid program, which provides free or low-cost health coverage to eligible low-income individuals and families. L.A. Care is one of the managed care plans that administers Medi-Cal benefits in Los Angeles County.
- Applied Behavior Analysis (ABA)
- A therapy based on the science of learning and behavior, most commonly used to treat Autism Spectrum Disorder (ASD). ABA services typically require prior authorization from the health plan before treatment can begin.
- ICD-10 / DSM-5 Diagnosis Codes
- Standardized medical codes used to identify a patient's diagnosis on authorization request forms. ICD-10 codes are the international classification system for diseases, while DSM-5 codes are specific to mental health and behavioral conditions.
- FMLA (Family and Medical Leave Act)
- A federal law that allows eligible employees to take up to 12 weeks of unpaid, job-protected leave per year for serious health conditions affecting themselves or a family member. Medical certification forms (WH-380-E and WH-380-F) are required to support an FMLA leave request.
- Medicare Part B
- The portion of Medicare that covers outpatient medical services, doctor visits, preventive care, and durable medical equipment. Enrollment requires a separate application and is subject to specific enrollment periods.
- IRMAA (Income-Related Monthly Adjustment Amount)
- An additional amount added to standard Medicare Part B and Part D premiums for individuals whose income exceeds certain thresholds. If your income has decreased due to a life-changing event, you can request a reduction using Form SSA-44.
- BCBA (Board-Certified Behavior Analyst)
- A credentialed professional who is qualified to design, supervise, and implement Applied Behavior Analysis (ABA) therapy programs. Many health plan ABA authorization forms require the supervising BCBA's credentials and National Provider Identifier (NPI).
- NPI (National Provider Identifier)
- A unique 10-digit identification number assigned to health care providers in the United States. It is required on most insurance and authorization forms to identify the billing or rendering provider.
- CPT Codes
- Current Procedural Terminology codes are standardized numeric codes used to describe medical, surgical, and diagnostic services on insurance and authorization forms. For example, codes 97151–97158 are commonly used for ABA therapy services.