California Department of Health Care Services Forms

This form is used for renewing your Medi-Cal benefits in the state of California.

This Form is used for renewing Medi-Cal benefits in California.

This document is used to determine the period of ineligibility for nursing facility level-of-care in California. It helps assess the level of care needed for individuals and determines the duration of ineligibility for nursing facility services.

This form is used for requesting patient records from the California Cancer Registry.

This document is a check list for requesting patient records from the California Cancer Registry.

This document is used for submitting a change in scope-of-service request for a freestanding Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) under the California Medi-Cal Cost Report program. It applies specifically to facilities that operate under the Prospective Payment System (PPS). The form provides instructions for completing and submitting the request.

This form is used for requesting program flexibility for a mental health rehabilitation center in California.

This Form is used for requesting program flexibility for psychiatric health facilities in California.

This form is used for renewing Medi-Cal benefits in California. It is available in Arabic language.

This form is used for renewing Medi-Cal benefits in California for individuals who speak Armenian.

This form is used for renewing Medi-Cal benefits in California. It is available in Farsi language.

This form is used for renewing Medi-Cal benefits in California. It is specifically designed for Chinese speakers.