California Department of Health Care Services Forms

This form is used for requesting information related to Medi-Cal in California. It is available in Korean language.

This form is used for requesting information related to Medi-Cal benefits in California. It is available in Arabic language.

This form is used for requesting information regarding Medi-Cal in California. It is available in Punjabi language.

This Form is used for submitting a request for information related to Medi-Cal in California. It is available in Russian language.

This Form is used for California residents who speak Lao and need to submit a request for information related to Medi-Cal.

This form is used for requesting information related to Medi-Cal benefits in California.

This form is used for requesting information related to Medi-Cal benefits in California. It is specifically designed for individuals who are Ukrainian-speaking.

This Form is used for submitting a Three-Year Program and Expenditure Plan or an Update Extension for the Mental Health Services Act (MHSA) in California.

This form is used for assessing and training Licensed Vocational Nurses (LVNs) in California. It helps evaluate the skills and abilities of LVNs and provides guidance for further training and professional development.

This form is used for sole proprietors in California to complete an application supplement.

This form is used for reporting Medi-Cal status in California.

This form is used for reporting student educational expenses as a supplement to the Medi-Cal Statement of Facts in California.

This Form is used for authorization for maintenance and/or transportation in California.

This document is used to notify recipients of the In-Home Supportive Services (IHSS) program in California that they are ineligible for exemption from workweek limits for extraordinary circumstances (Exemption 2).

This Form is used for California Children's Services Maintenance and/or Transportation Authorization in California.

This document is used for reporting outpatient screening information in Region B of California.

This Form is used for certification of multiple billing overrides in California. It is used to document the authorization for billings beyond the usual limitations.

This document provides the contact information for the point of contact for ground emergency medical transportation in California.

This form is used for certifying a branch approver's eligibility to access confidential mental health information in California.

This form is used for certifying vendors who need access to confidential mental health information in California. It ensures that vendors meet the necessary requirements and safeguards are in place to protect the privacy of mental health patients.

This form is used for certifying county approvers to gain access to the Department of Health Care Services Cost and Financial Reporting System (CFRS) in California.

This Form is used for certifying business partners as approvers to access confidential mental health information in California.

This Form is used for providing proof of citizenship and identity for Medi-Cal beneficiaries who are U.S. citizens or nationals in California.

This form is used for providing additional information related to the pickle eligibility or determination in California.

This Form is used for reporting personnel information for Home Care Organizations in California.

This Form is used for submitting staff information in California.

This form is used to acknowledge and document the affiliation and association between individuals or organizations in the state of California.

This form is used for applying for a protocol amendment in California.

This form is used for applying for coverage of coronavirus (Covid-19) testing costs in California. It is important to fill out this form to explore options for financial assistance with Covid-19 testing expenses.

This form is used for reporting facility staffing data in California.

This Form is used for express enrollment applicants in California to provide a notice and supplemental information.