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 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 6207 (2/15) - Medi-Cal Disclosure Statement
DHCS 6208 (11/11) - Medi-Cal Provider Agreement
DHCS 6209 (12/14) - Medi-Cal Supplemental Changes
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 6247 (11/07) - Authorization for Release of Protected Health Information
DHCS 6249 (08/19) - Appointment of Representative - Estate Recovery
DHCS 6251 (04/20) - Estate Recovery Questionnaire (Notice of Death)
DHCS 6251 (04/20) - Estate Recovery Questionnaire (Notice of Death) - Spanish
Back to forms index
