Formularios: DHCS 6000
Formularios: DHCS 6000
- DHCS 6002 (06/16) – Initial Treatment Provider Application
- DHCS 6011-1112 Direct Provider Narcotic Treatment Program – Alcohol and Drug (Excel)
Alt: Instructions - DHCS 6012-1112 Direct Provider Narcotic Treatment Program – Perinatal (Excel)
Alt: Instructions
- DHCS 6204 (01/13) – Medi-Cal Provider Application
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DHCS 6207 (2/15) – Medi-Cal Disclosure Statement
- DHCS 6208 (Rev. 07/2025) Acuerdo de proveedor de Medi-Cal
- DHCS 6209 (12/14) – Medi-Cal Supplemental Changes
- DHCS 6217 (11/21) – Successor Liability with Joint and Several Liability Agreement
- DHCS 6236 (Rev. 03/24) – Request for Access to Protected Health Information-Individual Request
- DHCS 6236 (Rev. 03/24) Spanish – Autorización Para La Divulgación De Información Médica Protegida
- DHCS 6249 (08/19) – Appointment of Representative – Estate Recovery
- DHCS 6251 (04/20) – Estate Recovery Questionnaire (Notice of Death)
- DHCS 6251 (04/20) – Estate Recovery Questionnaire (Notice of Death) – Spanish