​​​​​​​​Forms By Name - A

• Acceptable Citizenship and Identity Documents (DHCS 0007, 12/07)
  Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Laotian, Russian, Spanish​, Vietnamese
• Additional Children (Supplement to the Medi-Cal Statement of Facts, MC 210) (Eng/Sp) (MC 210 S-C, 05/07)
• Additional Family Members Requesting Medi-Cal (MC 371, 07/09)    
  Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Vietnamese
• Administrator/Director Information (DHCS 5082)
  
• Administrative Organization - Corporations (DHCS 5083)
• Administrative Organization - Public Agencies, Partnerships, Sole Proprietor, and Other Associations (DHCS 5084)
• Administrative Responsibility (DHCS 5085)
• Affidavit of Identity for U.S. Citizen or National Children Under 18 (DHCS 0009, 9/07)    
  Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese
• Affidavit of Identity for U.S. Citizens or National for Disabled Individuals Living in Institutional Care Facilities (DHCS 0010, 1/08)​
  
• Aged and Disabled Federal Poverty Level Program Financial Eligibility Form (MC 176 AD, 06/12) 
• Allocation/Special Deduction Worksheet (MC 176 W, 05/08)
• Annual Hemophilia Comprehensive Center Evaluation (DHCS 9054)
• Applicant's Supplemental Statement of Facts for Medi-Cal (MC 223, 05/07)    
  Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Vietnamese
• Application and Statement of Facts for an Individual Who is Over 18 and Under 21and Who was in Foster Care Placement on His or Her 18th Birthday (MC 250 A, 05/07)​
  
• Application and Statement of Facts for Child Not Living with a Parent or Relative and for Whom a Public Agency is Assuming Some Financial Responsibility (MC 250, 05/07)
  
• Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (DHCS 1801, 05/24)​
  
• Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (Spanish)​ (DHCS 1801 SP, 07/24)
  
• Application to Determine CCS Program Eligibility (DHCS 4480, 01/08)
  Alt: Spanish
• Appointment of Representative (MC 306, 06/07)    
  Alt: Spanish (01/08)
• Authorization for Release of Information (Large Print) (MC 220 14pt, 04/08)    
  Alt: Spanish
  
• Authorization for Release of Information (MC 220 8pt, 06/08)    
  Alt: Spanish
• Authorization for Release of ​PHI (DHCS 6247) ​