Forms: DHCS 6000

• DHCS 6002 (06/16) – Initial Treatment Provider Application
• DHCS 6011-1112 Kev Pab Kho Mob Yeeb Tshuaj Ncaj Qha - Cawv thiab Tshuaj (Excel)
  Alt:
  Cov Lus Qhia
• DHCS 6012-1112 Kev Pab Kho Mob Yeeb Tshuaj Ncaj Qha - Perinatal (Excel)
  Alt:
  Cov Lus Qhia
  
• DHCS 6204 (01/13) – Medi-Cal Provider Application
  
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  DHCS 6207 (2/15) – Medi-Cal Disclosure Statement
  
  
• DHCS 6208 (Rev. 07/2025) Daim Ntawv Pom Zoo Tus Muab Kev Pab Medi-Cal
  
• DHCS 6209 (12/14) – Medi-Cal Supplemental Changes
  
• DHCS 6217 (11/21) - Lub Luag Haujlwm Tom Qab Nrog Daim Ntawv Cog Lus Ua Ke thiab Ntau Lub Luag Haujlwm
  
• 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

Rov qab mus rau Forms Index