แบบฟอร์มโครงการรักษาผู้ป่วยด้วยยา Medi-Cal
- MC 5120AD – Vendor Approver Certification(PDF)
- MC 5121AD – County-Direct Provider Approver Certification(PDF)
- MC 5123AD – DHCS Employee Approver Certification (PDF)
- MC 5131AD – County-Direct Provider User Cancellation(PDF)
- DHCS 5311 Claim Form Attestation: Drug Medi-Cal (DMC) Claim for Reimbursement of Quality Assurance – Utilization Reassurance (QA/UR) Costs (PDF)
- Reach out to the BHFSOps@dhcs.ca.gov inbox for the claiming workbook that accompanies this claim form attestation.
- Reach out to the BHFSOps@dhcs.ca.gov inbox for the claiming workbook that accompanies this claim form attestation.
- แบบฟอร์มคำร้องขอ DHCS 5312 การรับรอง: คำร้องขอคืนเงินค่าใช้จ่ายการบริหารของเทศมณฑลจากบริการ Medi-Cal (DMC) สำหรับยา (PDF)
- Reach out to the SUDFMAB@dhcs.ca.gov inbox for the claiming workbook that accompanies this claim form attestation.
- DHCS 6065A Form – Good Cause Certification (PDF)
- DHCS 6065A Instructions – Good Cause Certification (PDF)
- DHCS 6065B Form – Good Cause Certification (PDF)
- DHCS 6065B Instructions – Good Cause Certification (PDF)
- DHCS 6700 Form – Multiple Billing Override Certification (PDF)
- DHCS 6700 Instructions – Multiple Billing Override Certification Instructions (PDF)
- DHCS 100185 Form – DMC Claim Submission Certification – Direct Contract Provider (PDF)
- DHCS 100185 Instructions – DMC Claim Submission Certification – Direct Contract Provider (PDF)
- DHCS 100186 Form – DMC Claim Submission Certification – County Contracted Provider (PDF)
- DHCS 100186 Instructions – DMC Claim Submission Certification – County Contracted Provider (PDF)
- DHCS 100187 Form – DMC Claim Submission Certification – County Operated Provider Form (PDF)
- DHCS 100224 – Drug Medi-Cal Certification for Federal Reimbursement (PDF) – Revised 04/2025
- DHCS 8049 Form – County Certification of Compliance (PDF) – Revised 04/2024
- DHCS 8049 Instructions – County Certification of Compliance (PDF)
- DHCS 5260 Form – SUDCRS Approver Form (PDF)