California Department of Health Care Services Forms

This form is used for appointing an authorized representative in California who can act on behalf of someone who speaks Russian.

This form is used for appointing an authorized representative in California, specifically for individuals who speak Punjabi.

This form is used for appointing an authorized representative in California who speaks Ukrainian.

This form is used for appointing an authorized representative in California. It specifically applies to individuals who are Thai and need assistance in their legal matters.

This form is used for appointing an authorized representative in California, written in Korean.

This Form is used for the California Health Access Program Family Pact Program to certify a client's eligibility. It is available in both English and Spanish.

This type of document is a Form MC14 in Spanish. It is used in California for the application of Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualified Individual (QI) programs.

This form is used for California residents who speak Tagalog and want to apply for the Qualified Low-Income Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individuals (QI) programs.

This Form is used for enrolling in Medi-Cal Managed Care Choice in Los Angeles County, California.

This document is used for selecting enrollment in Medi-Cal Managed Care, a health plan in Los Angeles County, California. It is available in Spanish.

This form is used for requesting a user ID for the Targeted Case Management (TCM) System in California.

This document provides instructions for submitting Medi-Cal Worksheets electronically for FQHC/RHC/IHS/MOA providers and FQHC/RHC home offices in California.