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Forms: DHCS 5000
DHCS 5018 - Order Form
DHCS 5021 - User Authorization
DHCS 5023 - Media Loan Request
DHCS 5024 - Consent for the Release of Confidential Information
DHCS 5050 - Facility Staffing Data
DHCS 5054 - Notice of Inspection of Confidential Records
DHCS 5077 - Health Screening Report
DHCS 5078 - Centrally Stored Medication and Destruction Record
DHCS 5079 - Unusual Incident/Injury/Death Report
DHCS 5080 - Personal Rights - Alcohol Recovery and Drug Treatment Facilities
DHCS 5080 SP - Derechos Personales - Facilidades de Recuperación y Tratamiento
DHCS 5082 - Administrator/Director Information
DHCS 5083 - Administrative Organization - Corporations
DHCS 5084 - Administrative Organization - Public Agencies, Partnerships, Sole Proprietor, and Other Associations
DHCS 5085 - Designation of Administrative Responsibility
DHCS 5086 - Weekly Activities Schedule
DHCS 5099 - CalOMS - ADP 100177 CalOMS ITWS County-Direct Provider Approver
DHCS 5100 - CalOMS - ADP 100178 CalOMS ITWS Vendor Approver
DHCS 5101 - CalOMS - ADP 100179 CalOMS ITWS Internal Employee Approver
DHCS 5102 - CalOMS - ADP 100180 CalOMS ITWS User Cancellation
DHCS 5103 - Client Health Questionnaire and Screening Questions
DHCS 5104 - Outpatient Fire Clearance
DHCS 5105 - Staff Health Questionnaire - Outpatient
DHCS 5111 - Application Supplement for Sole Proprietors Only
DHCS 5115 - Zoning Approval
DHCS 5140 - Disclosure to DHCS
DHCS 5255 - Supplemental Application Request for Additional Services
DHCS 5256 - Health Care Practitioner Incidental Medical Services Acknowledgement
DHCS 5999 - Request for License/Certification Extension
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Last modified date: 4/6/2026 10:09 AM
