DHCS Applications

The following are applications for individuals and providers to participate in DHCS programs:

Medi-Cal

• Provider Enrollment Application Packages Alphabetical by Provider Type
• Medi-Cal Mail-In Application, (multiple languages)
  
• Newborn Referral Form (MC 330)
  

• Health Insurance Premium Payment Application (SP)
  

California Children's Services (CCS)

The following are applications to enroll children and pregnant women in the Medi-Cal or Healthy Families program

• Application to Determine CCS Program Eligibility (DHCS 4480)
  Alt: Spanish 
  
• CCS Special Care Center Directory Update Form (DHCS 4507)
  

Disproportionate Share Hospital Program (DSH)

• DSH Release of Hospital Confidential Data

Fair Hearing (California Department of Social Services)

• Request for State Hearing before the State Department of Social Services
• Authorized Representative (Form DFA 19)
• Withdrawal/Conditional Withdrawals of Request for Hearing (Form DFA 315)

Hearing Conservation Program

• Application for Registrations as a School Audiometrist (PM 101)

Home and Community-Based 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)
  

Licensing and Certification Division (LCD)

• Licensing and Certification
• Driving-Under-the-Influence (DUI)
• Narcotic Treatment Programs (NTP)