​​​​​​​​​​Drug Medi-Cal Treatment Program Forms

• MC 5120AD - Vendor Approver Certification (PDF)
• MC 5121AD - County-Direct Provider Approver Certification (PDF)
• MC 5123AD - DHCS Employee Approver Certification (PDF)
• MC 5131AD - County-Direct Provider User Cancellation (PDF)
• DHCS 5311 Claim Form Attestation: Drug Medi-Cal (DMC) Claim for Reimbursement of Quality Assurance - Utilization Reassurance (QA/UR) Costs​ (PDF)
  
• ​Reach out to the BHFSOps@dhcs.ca.gov inbox for the claiming workbook that accompanies this claim form attestation. 
  
• DHCS 5312 Claim Form Attestation: Drug Medi-Cal (DMC) Services Claim for Reimbursement of County Administrative Expenses​​ (PDF)
• Reach out to the SUDFMAB@dhcs.ca.gov inbox for the claiming workbook that accompanies this claim form attestation.​ ​​
• DHCS 6065A Form - Good Cause Certification (PDF)
  
• DHCS 6065A Instructions - Good Cause Certification (PDF)
• DHCS 6065B Form - Good Cause Certification (PDF)
• DHCS 6065B Instructions - Good Cause Certification (PDF)
• DHCS 6700 Form - Multiple Billing Override Certification (PDF)
• DHCS 6700 Instructions - Multiple Billing Override Certification Instructions (PDF)
• DHCS 100185 Form - DMC Claim Submission Certification - Direct Contract Provider (PDF)
• DHCS 100185 Instructions - DMC Claim Submission Certification - Direct Contract Provider (PDF)
  
• DHCS 100186 Form - DMC Claim Submission Certification - County Contracted Provider (PDF)
• DHCS 100186 Instructions - DMC Claim Submission Certification - County Contracted Provider (PDF)
• DHCS 100187 Form - DMC Claim Submission Certification - County Operated Provider Form (PDF)​
  
• DHCS 100224 - Drug Medi-Cal Certification for Federal Reimbursement​ (PDF) - Revised 04/2025
  
• DHCS 8049 Form - County Certification of Compliance​ ​(​PDF) - Revised 04/2024
  
• DHCS 8049 Instructions - County Certification of Compliance​​ (PDF)
  
• DHCS 5260 Form - SUDCRS Approver Form (PDF)