California Department of Health Care Services Forms

This form is used for reporting the quarterly progress of the American Indian Infant Health Initiative (AIIHI) in California.

This form is used for the American Indian Infant Health Initiative (Aiihi) Database in California.

This form is used for reporting the enrollment and licensing information of participants in a 6-month DUI program in California on a quarterly basis.

This form is used for providing additional income and property information required for Medi-Cal eligibility in California.

This form is used to gather additional income and property information for Medi-Cal eligibility in California. It is specifically designed for Armenian-speaking individuals.

This form is used for providing additional income and property information needed for Medi-Cal in California. It is specific to the Hmong language.

This form is used for doctors to verify the need for home and community-based services in California, specifically under the spousal impoverishment provisions.

This form is used for providing additional income and property information needed for Medi-Cal in California. The form is available in Tagalog language.

This Form is used for providing additional income and property information needed for Medi-Cal in California. It is specifically designed for Chinese speakers.

This Form is used for verifying a doctor's approval for home and community-based services under spousal impoverishment provisions in California. The form is available in Arabic.

This form is used to provide additional income and property information for Medi-Cal eligibility in California for Cambodian residents.

This form is used for providing additional income and property information required for Medi-Cal in California. It is available in Arabic.

This form is used for providing additional income and property information needed for Medi-Cal in California. It is available in Vietnamese.

This form is used for doctors to verify the eligibility of individuals seeking home and community-based services under the spousal impoverishment provisions in California. It is specifically designed for individuals who speak Armenian.

This form is used to provide additional income and property information needed for the Medi-Cal program in California. It is available in Russian.

This document is used for the verification of a doctor for home and community-based services under spousal impoverishment provisions in California. It is specifically for Chinese language users.

This Form is used for providing additional income and property information needed for Medi-Cal in California. It is available in Korean language.

This type of document is a form used for verifying the doctor's services for caregivers under provisions that protect the spouse caregiver from impoverishment in California.

This form is used for doctors to verify the eligibility of individuals for Home and Community Based Services under the Spousal Impoverishment Provisions in California. (Mien)

This form is used for doctors to verify eligibility for Home and Community Based Services in California under the Spousal Impoverishment Provisions. The form is available in the Tagalog language.

This document is used for HMO doctors in California to verify the eligibility of patients for home and community-based services under spousal impoverishment provisions. The form is specific to the Hmong language.

This form is used for doctors in California to verify the eligibility of individuals for home and community-based services under the spousal impoverishment provisions. It is available in Korean language.

This Form is used for doctors to verify the eligibility of individuals for Home and Community Based Services in California under the Spousal Impoverishment Provisions.

This form is used for verifying a doctor's information for home and community-based services under spousal impoverishment provisions for California residents of Ukrainian origin.

This form is used by doctors in California to verify an individual's eligibility for home and community-based services under the spousal impoverishment provisions. It is specific to Russian language speakers.

This Form is used for doctors to verify the eligibility of individuals for Home and Community Based Services in California under the Spousal Impoverishment Provisions. This document is available in Punjabi.

This Form is used for doctors in California to verify eligibility for Home and Community Based Services under Spousal Impoverishment Provisions. It is available in Japanese.

This form is used for doctors to verify the eligibility of an individual for Home and Community Based Services under the Spousal Impoverishment Provisions in California. The form is available in Vietnamese language.

This Form is used for verifying the eligibility of a doctor for Home and Community Based Services under the spousal impoverishment provisions in California.

This document is used for doctors to verify the eligibility of patients for Home and Community Based Services under the Spousal Impoverishment Provisions in California. It is available in Farsi language.

This form is used for providing additional income and property information to apply for Medi-Cal in California. It is available in Farsi.

This type of document is used for submitting a new referral to the Genetic Handicap Program (GHPP) for individuals with genetic disabilities in California.

This Form is used for requesting the restriction of use and disclosure of protected health information at the Northern California Regional Office/San Francisco of the City and County of San Francisco, California.

This form is used for requesting to amend protected health information at the Southern California Regional Office in the City of Los Angeles, California.