California Department of Health Care Services Forms
The California Department of Health Care Services (DHCS) is responsible for ensuring access to quality, affordable healthcare for residents of California. They administer a variety of healthcare programs and services, including Medi-Cal, California's version of the Medicaid program, which provides healthcare coverage for low-income individuals and families. DHCS also oversees programs related to mental health services, substance use disorder treatment, and long-term care. Additionally, DHCS works to improve healthcare access and quality through policy development, program evaluation, and coordination with other healthcare stakeholders in the state.
Documents:
1049
This form is used for requesting the addition of family members to a medical plan in California.
PDF 
Word
This form is used for providers in California who only offer crossover services. It is a required document for providers to indicate their status as a crossover only provider.
This form is used for collecting basic information about a child who is seeking services from California Children's Services. It includes details such as the child's name, age, address, medical history, and insurance information.
This form is used for providing health insurance information in the state of California.
This Form is used for obtaining a sample Certificate of Live Birth in the state of California.
This form is used for applying for the CCS Medical Therapy Plan in California.
This form is used for requesting a waiver from the City and County of San Francisco, California.
This form is used for acknowledging incidental medical services provided by a health care practitioner in California.
This document is used for notifying the County of San Diego, California about the requirement for providing medical verification.
This Form is used for calculating Supplemental Security Income (SSI) for eligible children in California with an ineligible parent or parents. It provides a method for determining the child's income for the purpose of determining eligibility for SSI benefits.
This form is used for Medi-Cal certification and transmittal in the state of California. It is used to certify and transmit documents related to Medi-Cal eligibility and enrollment.
This form is used for applying for certification for county-owned and operated healthcare facilities in California.
This document provides a notice to patients in San Diego, California that they have been certified for up to 30 days of additional intensive treatment.
This form is used as a supplement to the Medi-Cal Mail-In Application in California. It specifically addresses real and personal property ownership.
This document is used for reporting the results of diagnostic audiologic evaluations as part of the California Newborn Hearing Screening Program in Region B.
This form is used for reporting the results of diagnostic audiologic evaluations as part of the California Newborn Hearing Screening Program.
This form is used for reporting diagnostic audiologic evaluations as part of the California Newborn Hearing Screening Program in Region D. It helps healthcare providers assess the hearing of newborns in California.
This form is used for reporting the diagnostic audiologic evaluation results as part of the California Newborn Hearing Screening Program in Region A.
This form is used for reporting the results of newborn hearing screening in California. It is specifically for outpatient screening and is part of the California Newborn Hearing Screening Program in Region A.
This form is used for the re-certification of county-owned and operated mental health providers in California. It is a self-survey form that helps ensure compliance with state guidelines and quality standards.
This form is used for submitting personal background history information to the California Department of Health Care Services (DHCS).
This form is used for documenting vocational and work history for individuals residing in California.
This form is used for California Chdp Providers to provide their data on the PM177 Data Sheet.
This form is used for creating a treatment plan for substance abuse prevention and control in the County of Los Angeles, California.
This form is used for the Child Health and Disability Prevention (CHDP) program in California. It is a pre-enrollment application for the program.
This form is used for obtaining consent to bridge coverage from Medi-Cal to Healthy Families in California.
This Form is used in California for explaining reasons for ineligibility for presumed eligibility.
This type of document is used for notifying eligible disabled individuals who are working in California. (Spanish)
This form is used for authorizing the release of hospital record information in the state of California. It allows individuals to give consent for their medical records to be shared with specified parties.
This Form is used for vendor approvers in California to certify their qualifications.
