Forms: DHCS 6000

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• DHCS 6001 (12/14) - Drug Medi-Cal Application
• DHCS 6002 (06/16) - Initial Treatment Provider Application
• DHCS 6011-1112 Direct Provider Narcotic Treatment Program - Alcohol and Drug  (Excel)   
      Alt: Instructions
  
• DHCS 6012-1112 Direct Provider Narcotic Treatment Program - Perinatal   (Excel)
      Alt: Instructions
  
• DHCS 6201 (05/14) - Medi-Cal Durable Medical Equipment Provider Application
  
• DHCS 6202 (01/13) - Medi-Cal Orthotics and Prosthetics Provider Application
  
• DHCS 6203 (01/13) - Medi-Cal Provider Group Application
  
• DHCS 6204 (01/13) - Medi-Cal Provider Application
  
• DHCS 6204 (01/13) - Medi-Cal Clinical Medical Laboratory Application
  
• DHCS 6204 (01/13) - Medi-Cal Clinic-Based Certified Nurse Midwife Application
  
• DHCS 6205 (05/14) - Medi-Cal Pharmacy Provider Application
  
• DHCS 6206 (01/13) - Medi-Cal Medical Transportation Provider Application
  
• DHCS 6207 (2/15) - Medi-Cal Disclosure Statement
  
• DHCS 6208 (11/11) - Medi-Cal Provider Agreement
  
• DHCS 6209 (12/14) - Medi-Cal Supplemental Changes
  
• DHCS 6210 (01/13) - Medi-Cal Physician Application/Agreement
  
• DHCS 6216 (02/15) - Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Provider
  
• DHCS 6217 (02/08) - Successor Liability with Joint and Several Liability Agreement
  
• DHCS 6219 (07/14) - Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement for Physician and Non-Physician Practitioners 
• DHCS 6236 (12/16) - Request for Access to Protected Health Information
  
• DHCS 6237 (12/16) - Request to Access Protected Health Information by Parent, Guardian or Personal Representative

• DHCS 6247 (11/07) - Authorization for Release of Protected Health Information
  
• DHCS 6248 (01/13) - Medi-Cal Nonphysician Medical Practitioner and Licensed Midwife Application

• DHCS 6249 (09/17) - Appointment of Representative - Estate Recovery

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