CenCal Health - Forms -HS Secure File Transfer for Authorization Request

HS Secure File Transfer for Authorization Request

Send files securely to CenCal’s Health Services UM Department

* Required fields are marked with asterisk

SENDER INFORMATION

Your Name*

Your Email*

Your Call Back Number*

MEMBER INFORMATION

Age Group*

Member Last Name*

Authorization Number*

< Please select below the type of documentation you are submitting >

Type:

< Please check URGENT ONLY if delaying member's treatment will affect life or limb >

Urgent

Message

*Note: Please do not upload any files with special characters in the file name (including quotation marks " "), as this will cause errors saving to our internal directories and make the file transfer fail*

Attached*

Drop files here, or browse to attach files

Confirmation Required

Are you sure you want to remove the selected file?

For assistance with this Form, please call Health Services UM Department at (805) 562-1082 or contact us on our website www.cencalhealth.org.

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