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Prior Authorization for Referrals

An HPSM-contracted PCP can refer patients to:

  • HPSM-contracted specialists without prior authorization
  • Specialists outside of HPSM’s network if an appropriate in-network specialist is not available

To refer to a non-network specialist:

  • Identify and contact the specialist provider to assure that he or she will be able to see the member on a timely basis and make arrangements to follow up after the visit
  • Fill out part 1 of the Referral Authorization Form and fax it to HPSM at 650-829-2079
  • Do not send an unauthorized RAF to the specialist’s office
  • If HPSM approves your request, an authorized RAF will be faxed to the specialist’s office
  • Upon receipt, the specialist can contact the member to schedule an appointment

Referral Forms
ACE Referral Authorization Form
Administrative Referral Authorization Form
Behavioral Health Referral Form
CBAS and MSSP Referral Form
Complex Case Management Referral Form
Home Health Physician Referral Form
Home Health Services - Retrospective Authorization Form
Referral Authorization Correction Form
Referral Authorization Form

Referral Authorization Fax Numbers

Out-patient referral:

650-829-2079

Behavioral Health and Recovery Services referral:

650-596-8065

CBAS and MSSP referral:

650-829-2047

Care Coordination referral:

650-829-2047