Forms: DHCS 6000
Forms: DHCS 6000
- DHCS 6002 – Initial Treatment Provider Application
- DHCS 6011-1112 Direct Provider Narcotic Treatment Program – Alcohol and Drug (Excel)
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Instructions - DHCS 6012-1112 Direct Provider Narcotic Treatment Program – Perinatal (Excel)
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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) Medi-Cal Provider Agreement
- 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