Tahanan Mga Porma, Batas, at Publikasyon Mga Form Mga Form ng Programa sa Paggamot ng Drug Medi-Cal

Mga Form ng Programa sa Paggamot ng Medi-Cal sa Droga

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.
DHCS 5312 Claim Form Attestation: Drug Medi-Cal (DMC) Services Claim para sa Reimbursement ng County Administrative Expenses (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)
Form ng DHCS 6065B – Sertipikasyon ng Mabuting Dahilan (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)
Form ng DHCS 100186 – Sertipikasyon sa Pagsusumite ng Claim ng DMC – Kontratadong Tagapagbigay ng Serbisyo ng County (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)