Applications

Applications for individuals and providers to participate in Health Care Services programs.

Medi-Cal

• Medi-Cal Mail-In Application, (multiple languages)
• Health Insurance Premium Payment Application (EN)
• Health Insurance Premium Payment Application (SP)
• Healthy Families/Medi-Cal Joint Application 
  To enroll children and pregnant women in the Medi-Cal or Healthy Families program. 

California Children's Services (CCS)

• Orthotic/Prosthetic Facility Application
• Individual Provider Paneling Application for Allied Health Care Professionals DHCS 4515
• Individual Provider Paneling Application for Physicians and Poediatrists DHCS 4514
• CCS Special Care Center Directory Update DHCS 4507

Child Health and Disability Prevention (CHDP) Program

• CHDP Health Assessment Provider Application DHCS 4490
• CHDP Health Assessment Provider Program Agreement DHCS 4491
• CHDP Laboratory Provider Application DHCS 4502
• CDHP Laboratory Provider Program Agreement DHCS 4503
• CHDP Pre-Enrollment Application DHCS 4073
• CHDP Telecommunications Provider and Biller Application/Agreement DHCS 4431
• Newborn Referral Form MC 330

Disproportionate Share Hospital Program (DSH)

• DSH Hospital Address Questionnaire
• DSH Health Plan Address Questionnaire 
• DSH Obstetrician Availability Certification
• DSH Release of Hospital Confidential Data

Fair Hearing

• Request for State Hearing before the State Department of Social Services
• Authorized Representative
• Withdrawal/Conditional Withdrawals of Request for Hearing

Genetically Handicapped Persons Program (GHPP)

• Application to Determine GHPP Program Eligibility
• Application to Determine GHPP Financial Eligibility

Hearing Conservation Program

• Application for Registrations as a School Audiometrist PM 101

Home and Community-Base Services Branch (HCBS)

• Home and Community-Based Services Branch (HCBS)
 

Newborn Hearing Screening Program

• Communication Disorder Center Application DHCS 4482
• Outpatient Infant Hearing Screen Provider Application DHCS 4481