Mga Form: DHCS 5000
DHCS 5018 – Order Form
DHCS 5021 – User Authorization
DHCS 5023 – Media Loan Request
DHCS 5024 – Consent for the Release of Confidential Information
DHCS 5050 – Facility Staffing Data
DHCS 5054 – Notice of Inspection of Confidential Records
DHCS 5077 – Health Screening Report
DHCS 5078 – Centrally Stored Medication and Destruction Record
DHCS 5079 – Unusual Incident/Injury/Death Report
DHCS 5080 – Personal Rights – Alcohol Recovery and Drug Treatment Facilities
DHCS 5080 SP – Derechos Personales – Facilidades de Recuperación y Tratamiento
DHCS 5082 – Administrator/Director Information
DHCS 5083 – Administrative Organization – Corporations
DHCS 5084 – Administrative Organization – Public Agencies, Partnerships, Sole Proprietor, and Other Associations
DHCS 5085 – Designation of Administrative Responsibility
DHCS 5086 – Weekly Activities Schedule
DHCS 5099 – CalOMS – ADP 100177 CalOMS ITWS County-Direct Provider Approver
DHCS 5100 – CalOMS – ADP 100178 CalOMS ITWS Vendor Approver
DHCS 5101 – CalOMS – ADP 100179 CalOMS ITWS Internal Employee Approver
DHCS 5102 – CalOMS – ADP 100180 CalOMS ITWS User Cancellation
DHCS 5103 – Client Health Questionnaire and Screening Questions
DHCS 5104 – Outpatient Fire Clearance
DHCS 5105 – Staff Health Questionnaire – Outpatient
DHCS 5111 – Application Supplement for Sole Proprietors Only
DHCS 5115 – Zoning Approval
DHCS 5140 – Disclosure to DHCS
DHCS 5255 – Supplemental Application Request for Additional Services
DHCS 5256 – Health Care Practitioner Incidental Medical Services Acknowledgement
DHCS 5999 – Request for License/Certification Extension