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 6208 (Rev. 07/2025) Medi-Cal Provider Agreement
  
• 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

Back to forms index