California Department of Managed Health Care Forms

This document is a form used by California managed care members to file a grievance about their healthcare services.

This Form is used for terminating benefits with Cobra Continuation Services in California.

This Form is used for filing a complaint or requesting an Independent Medical Review (IMR) in California in Spanish.

This form is used for submitting an Independent Medical Review (IMR) application or complaint form in California. It is available in Arabic language.

This Form is used for filing an Independent Medical Review (IMR) Application/Complaint in California. It is available in Hindi.

This form is used for submitting an application or complaint for an Independent Medical Review (IMR) in California. It is available in Armenian language.

This document is a form used for filing an Imr application/complaint in California. It is available in Chinese language.

This document is a form used for filing an Imr Application/Complaint in California. It is available in the Khmer language.

This form is used for filing an Independent Medical Review (IMR) application or complaint in California. It is available in Farsi language for individuals who prefer to communicate in Farsi.

This Form is used for filing an Independent Medical Review (IMR) application or complaint in California. It is available in Tagalog language.

This form is used for filing an application or complaint for an Independent Medical Review (IMR) in California. It is available in Thai language to cater to the Thai-speaking residents.

This form is used for submitting an independent medical review (IMR) application or complaint in California. The form is provided in Punjabi language for those who prefer to fill it out in that language.

This form is used for filing an Independent Medical Review (IMR) Application/Complaint in California. It is available in the Lao language.

This form is used for filing an Imr application or complaint in California. It is available in Korean language.

This form is used for submitting an application or complaint for an Independent Medical Review (IMR) in California. It is available in Japanese language.

This Form is used for submitting an application or complaint related to independent medical review (IMR) in California. It is available in Vietnamese language.

This form is used for individuals in California to authorize an assistant to act on their behalf in matters related to the Department of Managed Health Care (DMHC).

This form is used for appointing a legal representative for a deceased patient in California. It allows the representative to make decisions on behalf of the deceased regarding their healthcare matters.

This form is used for electronic filing signature verification in California.

This document is used for tracking and organizing information about subcontractors working in California. It helps ensure that all necessary details are recorded accurately for payroll purposes, project management, and legal compliance.

This form is used for registering as a Pharmacy Benefit Manager in the state of California.

This form is used for applying for an exemption from the Employee Assistance Program (EAP) requirements in California.

This document is a filing worksheet specifically designed for dental and health plans in California. It helps with organizing and recording the necessary information required for filing purposes.

This form is used for verifying electronic signatures for filing documents in California.

This document is a questionnaire that is used in California to assess and evaluate a Risk-Bearing Organization (RBO). The questionnaire aims to gather information about the organization's risk management practices and ensure compliance with relevant regulations.