California Department of Health Care Services Forms

This form is used for requesting an accounting of the disclosure of protected health information by a parent, guardian, or legal representative in the Genetically Handicapped Persons Program in California.

This Form is used for parents, guardians, or legal representatives in Sacramento, California to request the amendment of protected health information.

This document is a form used to request restrictions on the use and disclosure of protected health information in the Southern California Regional Office of the City of Los Angeles, California.

This form is used for requesting access to protected health information under the Genetically Handicapped Persons Program in California.

This form is used for requesting the suspension of Medi-Cal payment eligibility in California.

This Form is used for submitting drug Medi-Cal (Dmc) claims for Direct Contract Providers in California.

This document is used for submitting drug Medi-Cal (DMC) claims as a contracted provider in California. It provides instructions on how to complete the Form DHCS100186 for claiming reimbursement for DMC services.

This Form is used for submitting claims for Drug Medi-Cal services provided by County Operated Providers in California.

This Form is used for submitting drug Medi-Cal (Dmc) claims by County Operated Providers in California. The form serves as a certification for claim submission.

This Form is used for applying for Good Cause Certification in California. It is required for individuals who are seeking an exemption from certain Medi-Cal eligibility requirements.

This form is used for County/Direct Provider Approver Certification in the state of California. It is important for certifying individuals who approve certain services for county or direct providers.

This type of document is used for making a medical diagnosis report declaration in California.

This Form is used for healthcare providers and groups in California to affiliate or disaffiliate with the Medi-Cal program.

This form is used for county approvers and vendors to certify and appoint access to the California Outcomes Measurement System (Caloms Tx) in California.

This Form is used for providers to agree to the terms and conditions of the Medi-Cal program in California when applying for enrollment or continued enrollment.

This form is used for California physicians to apply for and agree to participate in the Medi-Cal program.

This form is used for applying for a Medi-Cal Clinical Medical Laboratory in California.

This form is used for applying to become a non-physician medical practitioner or licensed midwife under the Medi-Cal program in California.

This Form is used for disclosing information related to Medi-Cal benefits in the state of California.

This Form is used for institutional healthcare providers in California who wish to enter into a Medi-Cal provider agreement.

This form is used for individual physicians or dentists who are relocating their practices within the same county in California to make changes to their Medi-Cal location information.

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

This form is used for determining the income eligibility of qualified disabled working individuals (QDWIs) and their spouses. It includes instructions for couples or applicants with an ineligible spouse, with or without children, who reside in California.

This form is used for health care practitioners in California to certify their ability to provide incidental medical services to clients.

This form is used for updating the Special Care Center (SCC) directory in California. It serves as a cover sheet for submitting the necessary information for updating the directory.

This Form is used for collecting and recording data on facility staff in the state of California. It is used by the Department of Health Care Services (DHCS) to gather information about individuals employed at healthcare facilities such as hospitals, nursing homes, and clinics. The form includes details about staff members' employment history, qualifications, and certifications.

This Form is used for requesting personal rights for recovery and treatment facilities in California.

This Form is used for providing Administrator/Director Information in the state of California.

This form is used for establishing the administrative organization of public agencies, partnerships, sole proprietorships, and other associations in California.