Mental Health Forms

Medi-Cal Manual Claim Forms

MC 1982 A: SD/MC Quarterly Claim for Reimbursement - Treatment Cost
MC 1982 B: SD/MC Quarterly Claim for Reimbursement - Administrative Cost.xls
MC 1982 C: SD/MC Monthly Claim for Reimbursement - Quality Assurance/Utilization Review (QA/UR) Cost
MC 1982 D: SD/MC Quarterly Claim for Reimbursement - Medi-Cal Administrative Activities (MAA)
MC 1982 G: SD/MC Quarterly Claim for Reimbursement - Medi-Cal Administrative Activities (MAA)

BHIS Certification Forms

DHCS 5259 (06/16): CSI County Approver Certification & Vendor Appointment Form
DHCS 5262 (Rev. 07/17): DCR County Approver Certification and Vendor Appointment Form
DHCS 5260 (Rev. 06/18): FAST County Approver Certification & Vendor Appointment Form
DHCS 5267 (12/19): Provider Information Management System (PIMS) County Approver Certification & Vendor Appointment Form

DHCS Application Portal Approval Forms

ITWS Certification Forms

Mental Health Certification Forms

Other Mental Health Forms

Last modified date: 12/10/2019 3:36 PM