Medi-Cal Manual Claim Forms 

MC 1982 A: Specialty Mental Health Services Medi-Cal Certification for Federal Reimbursement (Revised 04/2025)
DHCS 1982 B Attestation: Medi-Cal Specialty Mental Health Services Quarterly Claim for Reimbursement – Administrative Cost 
Reach out to the BHFSOps@dhcs.ca.gov inbox for the claiming workbook that accompanies this claim form attestation. 
California DHCS Medi-Cal Countywide Averages for State Fiscal Year 2023-24 Quarters 1-4
DHCS 1982 C Attestation: Medi-Cal Specialty Mental Health Services Quarterly Claim for Reimbursement – Quality Assurance/Utilization Review (QA/UR) Cost
Reach out to the BHFSOps@dhcs.ca.gov inbox for the claiming workbook that accompanies this claim form attestation. 
MC 1982 D: SD/MC Quarterly Claim for Reimbursement – Medi-Cal Administrative Activities (MAA)
MC 1982 G: SD/MC Quarterly Claim for Reimbursement – Medi-Cal Administrative Activities (MAA)

BHIS Certification Forms

• DHCS 5259 (Rev. 09/2021): CSI County Approver Certification & Vendor Appointment Form
• DHCS 5268 (06/2025): FAST County Approver Certification & Vendor Appointment Form
• DHCS 5262 (Rev. 08/2025): DCR County Approver Certification and Vendor Appointment Form
• DHCS 5267 (12/2019): Provider Information Management System (PIMS) County Approver Certification & Vendor Appointment Form

DHCS Application Portal Approval Forms

• DHCS 7000 (09/2019): County Approver Certification Form – SDMC-Mental Health
• DHCS 7204 (09/2019): County Approver Certification Form – SDMC-Alcohol and Drug Programs
• DHCS 7201 (09/2019) County Approver Certification Form – Cost and Financial Report Systems
• DHCS 7202 (09/2019) County Approve Certification Form – Consumer Perception Survey

ITWS Certification Forms 

• MC 5254: ITWS Business Partner Certification
• MC 5257: ITWS DHCS Employee Certification
• MC 5258: ITWS Vendor Certification
• MC 5273: ITWS County Certification

Mental Health Certification Forms

DHCS 1800 (MH 300): Electroconvulsive Treatment (ECT), Informed Consent Form
DHCS 1800 SP: Electroconvulsive Treatment (ECT), Informed Consent Form (Spanish)
DHCS 1801 (MH 302): Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment
DHCS 1801 SP: Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (Spanish)
DHCS 1802 (MH 303): Involuntary Patient Advisement
DHCS 1802 SP: Involuntary Patient Advisement (Spanish)
DHCS 1803 (MH 306): Patient Rights Denial – Monthly Talley
DHCS 1804 (MH 307): Denial of Rights/Seclusion & Restraint – Monthly
DHCS 1805 (MH 308): Denial of Rights/Seclusion & Restraint – Quarterly
DHCS 1806 (MH 309): Convulsive Treatments Administered – Quarterly Report (use DHCS 1011)
DHCS 1807 (MH 560): Authorization for Release of Protected Health Information and Confidential Information
DHCS 1807 SP: Authorization for Release of Protected Health Information and Confidential Information (Spanish)
DHCS 1808 (MH 1760): Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 DaysIntensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment for Grave Disability) of the Welfare and Institutions Code
DHCS 1808 SP: Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 DaysIntensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment for Grave Disability) of the Welfare and Institutions Code (Spanish)
DHCS 1809 (MH 1761): Notice of Certification for Additional 14 Days Intensive Treatment
DHCS 1810: Inventory of County 5150 Designated Facilities
DHCS 1811 (MH 5671): Authorization for Release of Patient Information
DHCS 1812 (MH 5756): Voluntary Admission Application for Mentally Disabled Person
DHCS 1819 Mental Health Services Act (MHSA) Prudent Reserve Assessment/Reassessment
DHCS 1820 Annual MHSA Revenue and Expenditure Report and Adjustment Worksheet County Certification
DHCS 1821 MHSA: Adjustments to Revenue and Expenditure Summary Worksheet
DHCS 1822A Annual MHSA Annual Revenue and Expenditure Report Template and Instructions

Other Mental Health Forms

DHCS 1011 (11/2022): Quarterly Report for Convulsive Treatment and Psychosurgery Administered
DHCS 1012 (12/2022): Program Flexibility Form for Mental Health Rehabilitation Center
DHCS 1013 (12/2022): Program Flexibility Form for Psychiatric Health Facility
DHCS 1735 Medi-Cal (M/C) Certification Transmittal (09/2014)
DHCS 1736 County-Owned and Operated Certification Application (09/2014)
DHCS 1737 County-Owned and Operated Provider Self-Survey Form (09/2014)
DHCS 1739 (08/2024): Mental Health Professional Licensing Waiver Request
DHCS 1740 (05/2020):Delegation of Approval TasShort-Term Residential Therapeutic Program
DHCS 1746 Director’s Designee Information
DHCS 1813 (08/2022): Application for Licensure – Mental Health Rehabilitation Center (MHRC)
DHCS 1816 Affidavit Regarding Client Money (MHRC)
DHCS 1814 (08/2022): Application for Licensure – Psychiatric Health Facility (PHF)
DHCS 1817 Affidavit Regarding Patient Money (PHF)
DHCS 1815 (1/2025): Application for a Special Permit of Structured Outpatient Services
DHCS 1818 (07/2014) Criminal Record Approval Transfer Notification
DHCS 3007 PERSONAL BACKGROUND HISTORY STATEMENT
DHCS 3085 CRIMINAL BACKGROUND CHECK: CHARACTER REFERENCE
DHCS 6030 Application for Initial Licensure for Psychiatric Residential Treatment Facility (PRTF)
DHCS 6031 Psychiatric Residential Treatment Facility Affidavit Regarding Resident Money (PRTF)
DHCS 6032 Annual Attestation of Compliance with Subpart G of Part 483 of Title 42 of the Code of Federal Regulations
DHCS 6033 Application for Renewal of License for Psychiatric Residential Treatment Facility (PRTF)