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Forms: DHCS 6000
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 6207 (2/15) - Medi-Cal Disclosure Statement
DHCS 6209 (12/14) - Medi-Cal Supplemental Changes
DHCS 6217 (11/21) - Successor Liability with Joint and Several Liability Agreement
DHCS 6236 (Rev. 03/24) - Request for Access to Protected Health Information-Individual Request
DHCS 6236 (Rev. 03/24) Spanish - Autorización Para La Divulgación De Información Médica Protegida
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
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Last modified date: 2/20/2025 2:55 PM
