​​​​​Online Conlan Claim Forms

​Return to Medi-Cal Out-of-Pocket Expense Reimbursement (Conlan)​

​Conlan Claim Packet

The Conlan claim packet below is available for you to (1) fill-out online and print or (2) to print and fill-out manually, if you would like to request reimbursement (refund) from the Medi-Cal program for medical, pharmacy, and/or dental expenses you paid.

Conlan Claim Packet Contents

The completed Conla​​n claim packet must include all the following:

• A photocopy of your Medi-Cal Beneficiary Identification Card (BIC).

• Proof of payment.  Examples include a copy of a cancelled check(s) from the bank (front and back), receipt(s) from the provider you paid, evidence of electronic payment, or a copy of a money order. A declaration may be used in some situations to explain, supplement, or support the documents above.​
  

• For those services that require Medi-Cal authorization, documentation from the medical or dental provider that shows medical necessity for the service.

• An itemized billing statement indicating the date(s) of service; and the service(s) and/or service code(s) for which you paid out-of-pocket to the provider(s)
  

• A completed Medi-Cal Claim Form for Beneficiary Reimbursement​ (DHCS 4521)

• A completed Payee Data Record Form​ (STD 204)​

• Authorization for Release of Information (MC 220) - Optional
  

• Appointment of Authorized Representative (MC 382) - Optional
  

​​​Important Beneficiary Reference Documents

• Taglines
• Notice of Non-Discrimination

Claim Packet Submission Dates

Beneficiary claim packet must be received within 1 year from the date of service or 90 days from the date of when beneficiary's Medi-Cal card was issued, whichever is later.

​Mail Claim Packet