Skip to Main Content
  • Home
  • #
  • #
  • #
  • Home
  • About DHCS
  • Translate
CA.gov logo
DHCS logo
Menu Search
  • Home
  • Services
  • Individuals
  • Providers &
    Partners
  • Laws &
    Regulations
  • Data &
    Statistics
  • Forms &
    Publications
  • Search
Page Content

​​​​​​ 

​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 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

Last modified date: 7/10/2020 10:33 AM


Non-Discrimination Policy and Language Access

Access Health Care Language Assistance Services (SB 223)


العربية   |   Հայերեն   |   ខ្មែរ   |   繁體中文   |   فارسی   |   हिंदी   |   Hmoob   |   日本語   |   한국어   |   ລາວ   |   ਪੰਜਾਬੀ   |   Русский   |   Español   |   Tagalog   |   ภาษาไทย   |   Tiếng Việt


About Us   |   Careers   |   Conditions of Use   |   Privacy Policy   |   Contact Us   |   Accessibility Certification

Copyright © State of California