Formularios: DHCS 6000
Formularios: DHCS 6000
- DHCS 6002 – Initial Treatment Provider Application
- DHCS 6011-1112 Program de tratamiento de narcóticos con proveedor directo – Alcohol y Drogas (Excel)
Alternativa:
Instrucciones - DHCS 6012-1112 Direct Provider Narcotic Treatment Program – Perinatal (Excel)
Alt:
Instructions - DHCS 6040 – Initial Application for Certification
- DHCS 6041 – Initial Application for Existing Certified Programs To Obtain Initial Certification for New Program
- DHCS 6042 – Application for Certification Amendment
- DHCS 6043 – Application for Certification Renewal
- DHCS 6045 – Detoxification Observation – Vital Signs Check Log
- DHCS 6046 – Detoxification Observation – Physical Check Log
- DHCS 6047 – Application for Existing Licensee to Obtain Initial Licensure for New Facility
- DHCS 6048 – Consent to Electronic Service Agreement
- DHCS 6204 (02/17) – Medi-Cal Provider Application
- DHCS 6207 (2/17) – Medi-Cal Disclosure Statement
- DHCS 6208 (Rev. 07/2025) Acuerdo de proveedor de Medi-Cal
- DHCS 6209 (14/12) – Cambios suplementarios de Medi-Cal
- DHCS 6217 (11/21) – Responsabilidad sucesoria con acuerdo de responsabilidad solidaria
- DHCS 6236 (Rev. 24/03) – Solicitud de acceso a información sanitaria protegida - Solicitud individual
- DHCS 6236 (Rev. 03/24) Spanish – Autorización Para La Divulgación De Información Médica Protegida
- DHCS 6249 (08/19) – Nombramiento de representante – Estate Recovery
- DHCS 6251 (04/20) – Estate Recovery Questionnaire (Notice of Death)
- DHCS 6251 (04/20) – Estate Recovery Questionnaire (Notice of Death) – Spanish