California Department of Health Care Services Forms

This form is used for conducting a Staying Healthy Assessment for adults in California.

This form is used for reporting the results of a health examination required for entry into school in California.

This form is used for the Staying Healthy Assessment for infants aged 0-6 months in California, with a specific version available in the Hmong language.

This Form is used for making a commitment to pay the reimbursable Medi-Cal lien amount in California.

This document provides a list of adult questions categorized by age group in California. It can help individuals find specific information relevant to their age.

This document provides a list of pediatric sha questions categorized by age group in California. It helps parents and caregivers understand what questions to ask their child's healthcare provider at different stages of childhood.

This document is used for County Approvers in California to certify and appoint vendors for certain services. It is a requirement for vendors to be approved by the County Approvers before they can provide their services.

This form is used for submitting an affidavit regarding patient money at a psychiatric health facility in California.

This form is used for applying for a special permit to operate a Psychiatric Health Facility & Program for Structured Outpatient Services (SOPs) in California.

This form is used for notifying the California Department of Health Care Services (DHCS) about the transfer of criminal record approvals.

This form is used for conducting a criminal background check in California. It includes a character reference section to gather information about an individual's character and reputation.

This document is used to obtain consent from individuals in California to release and exchange their personal information with other parties.

This form is used for reporting outpatient screening results for the California Newborn Hearing Screening Program in Region C.

This form is used for reporting outpatient screening for newborn hearing in Region D of the California Newborn Hearing Screening Program.

This Form is used for conducting a medical record review in California. It provides instructions for completing Form DHCS4492, which is used to gather information about a patient's medical history and treatment. The tool is designed to help healthcare professionals assess the quality and appropriateness of care provided to patients.

This form is used for pre-enrollment application for the Child Health and Disability Prevention (CHDP) Program in California.

This form is used for pre-enrollment in the Child Health and Disability Prevention (CHDP) Program in California. It is available in Arabic language for non-English speakers.

This Form is used for making Chdp Referral in California.

This form is used for pre-enrollment in the Child Health and Disability Prevention (CHDP) Program in California. It is available in Farsi.

This Form is used for submitting a Medi-Cal Supplemental Cost Report in California. It provides instructions on how to accurately complete and submit the required information.

This Form is used for reporting the home office costs for Medi-Cal providers in California. It provides instructions and guidance on how to prepare and submit the cost report accurately.

This document is used for completing a Multiple Billing Override Certification form in California. It is used to certify that multiple billings have been authorized for specific services.

This document is a checklist to help businesses in California develop an operational plan. It outlines key areas to consider and tasks to complete for effective planning and management.

This document is a checklist used in California for maintaining public health case records. It ensures that all necessary information is included in the records for efficient record-keeping and data analysis.