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
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• 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) – 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​​ 

Rov qab mus rau Forms Index​​