Medi-Cal: Forms

References

Forms

Medi-Cal providers and billers may view and download the following forms. For information about completing and submitting these forms, please review the appropriate provider manual section.

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Billing (CMC, EFT Payments, Hardcopy & POS)

Computer Media Claims (CMC)
	Application/Agreement Form Attachment for EMC*Express Users	MC 88-G-9
	CHDP Telecommunications Provider and Biller Application/Agreement	DHCS 4431
	Electronic Health Care Claim Payment/Advice Receiver Agreement (ANSI ASC X12N 835 Transaction)	DHCS 6246
	Medi-Cal Telecommunications Provider and Biller Application/Agreement CMC Enrollment Procedures CMC Enrollment Checklist 837 Claim Attachment Guidelines for Providers and Vendors	DHCS 6153
	Attachment Control Form (ACF) - Call Telephone Service Center (TSC) 1-800-541-5555 to order ACF Completion Instructions (pg. 4)	ACF-001
EFT Payments-Automatic Deposits
	EFT Enrollment Authorization [Fillable]
Hardcopy
	Biller: Medi-Cal Hardcopy Biller Application Agreement
	Provider: Medi-Cal Hardcopy Biller Notification Form
Point of Service (POS) Network
	Automated Eligibility Verification System (AEVS) Response Log General Information
	Medi-Cal Eligibility Verification Enrollment Form
	Medi-Cal Point of Service (POS) Network/Internet Agreement
	Point of Service (POS) Device Usage Agreement

California Children's Services (CCS)

	CCS Program Individual Provider Paneling Application for Allied Health Care Professionals	DHCS 4515
	CCS Program Individual Provider Paneling Application for Physicians and Podiatrists	DHCS 4514
	CCS/GHPP Discharge Planning Service Authorization Request (SAR)	DHCS 4489
	Established CCS/GHPP Client Service Authorization Request (SAR)	DHCS 4509
	New Referral CCS/GHPP Client Service Authorization Request (SAR)	DHS 4488

Cancer Detection

Consent to Participate in Program and Privacy Statements
	Consent to Participate in Program and Privacy Statement (English)	CDPH 8478
	Consent to Participate in Program and Privacy Statement (Cantonese)	CDPH 8478
	Consent to Participate in Program and Privacy Statement (Chinese Mandarin)	CDPH 8478
	Consent to Participate in Program and Privacy Statement (Korean)	CDPH 8478
	Consent to Participate in Program and Privacy Statement (Russian)	CDPH 8478
	Consent to Participate in Program and Privacy Statement (Spanish)	CDPH 8478
	Consent to Participate in Program and Privacy Statement (Vietnamese)	CDPH 8478
Recipient Eligibility
	Recipient Eligibility Form	CDPH 8699, English
	Recipient Eligibility Form	CDPH 8699, Spanish
Breast and Cervical Data Entry Worksheets & Instructions
	Breast Cancer Screening Cycle Data Worksheet
	Breast Cancer Screening Cycle Data Instructions
	Cervical Cancer Screening Cycle Data Worksheet
	Cervical Cancer Screening Cycle Data Instructions
Reimbursable Procedures
	Breast & Cervical Primary Care Provider Reimbursable Procedures
	Breast Only Primary Care Provider Reimbursable Procedures
	Referral Provider Reimbursable Procedures

Facilities & Hospitals

Distinct-Part Nursing Facilities (DP/NF)
	Call List for NF Placement
	Family Certification	DHS 6223
	Medical Certification	DHS 6224
	Medi-Cal Information Sheet for Hospital-Based Nursing Facility Patients (English) Additional Information and Instructions
	Medi-Cal Information Sheet for Hospital-Based Nursing Facility Patients (Spanish)
Hospice
	Hospice General Inpatient Information Sheet Instructions	DHS 6194
Inpatient Non-Contract Hospital
	Revenue Rate Change Request	DHS 6004
Public Hospital Outpatient Services
	Facility Cost and Charge Worksheet Instructions
	Public Hospital Outpatient Services Supplemental Reimbursement Claim and Certification Form 2002-2003 Instructions
	Public Hospital Outpatient Services Supplemental Reimbursement Worksheet Instructions
Quality Assurance Fee (QAF)
	Quarterly Payment Designated Intermediate Care Facility (DICF)	DHCS 9085
	Annual Report Designated Intermediate Care Facility (DICF)	DHCS 9102

Presumptive Eligibility for Pregnant Women

Presumptive Eligibility
	Presumptive Eligibility Forms Order	MC 285
	Provider Directions for Presumptive Eligibility Application	MC 263
	Qualified Provider Application for Presumptive Eligibility Participation and Presumptive Eligibility Qualified Provider Responsibilities and Agreement	MC 311
	Statement of California Residency	MC 263-SR
	Presumptive Eligibility Patient Fact Sheet	MC 264
	Patient Directions for Presumptive Eligibility Application	MC 265
	Directions to Apply for Medi-Cal	MC 266
	Explanation of Ineligibility for Presumptive Eligibility	MC 267
	Weekly Presumptive Eligibility (PE) Enrollment Summary	MC 283
	Presumptive Eligibility Provider Fact Sheet	MC 286

Provider Enrollment

Out-of-State Provider Please contact the Out-of-State Provider Unit for requirements and more information.
	Out-of-State Provider Express Enrollment
Applications For more information: Provider Enrollment Division (PED)
	Medi-Cal Clinical Medical Laboratory Application (revised 2/08) [Fillable]	DHCS 6204
	Medi-Cal Disclosure Statement (revised 2/08) [Fillable]	DHCS 6207
	Medi-Cal Durable Medical Equipment Provider Application (revised 2/08) [Fillable]	DHCS 6201
	Medi-Cal Medical Transportation Provider Application (revised 2/08) [Fillable]	DHCS 6206
	Medi-Cal Nonphysician Medical Practitioner and Licensed Midwife Application (revised 2/08) [Fillable]	DHCS 6248
	Medi-Cal Orthotics and Prosthetics Provider Application (revised 2/08) [Fillable]	DHCS 6202
	Medi-Cal Pharmacy Provider Application (revised 2/08) [Fillable]	DHCS 6205
	Medi-Cal Physician Application/Agreement (revised 2/08) [Fillable]	DHCS 6210
	Medi-Cal Provider Agreement (revised 2/08) [Fillable]	DHCS 6208
	Medi-Cal Provider Application (revised 2/08) [Fillable]	DHCS 6204
	Medi-Cal Provider Group Application (revised 2/08) [Fillable]	DHCS 6203
	Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (revised 2/08) [Fillable]	DHCS 6216
	Medi-Cal Supplemental Changes (revised 2/08) [Fillable]	DHCS 6209
	Medi-Cal Hospital-Based Physician Application/Disclosure Statement/Agreement (new 7/08) [Fillable]	DHCS 9095
	Medi-Cal Change Of Location Form For Individual Physician Practices Relocating Within The Same County (new 7/08) [Fillable]	DHCS 9096
	Medi-Cal Provider Agreement - Institutional Provider (new 8/08) [Fillable]	DHCS 9098
Facilities Only
	"Pay-To" Address Change Notification	DHCS 6129
General
	Medi-Cal Provider Data Form [Fillable]	MC 803
	Medi-Cal Provider Number Verification Form
	Medi-Cal Certification of Compliance [Fillable]
	Successor Liability with Joint and Several Liability Agreement (revised 2/08) [Fillable]	DHCS 6217
	National Provider Identifier Registration Form (revised 6/08) [Fillable]	DHCS 6218

Supplies, Injections & DUR

	Incontinence Supplies Prescription Form Instructions
	Recombinant Human Erythropoietin (RheEPO) Documentation Requirements Additional Information
	Drug Rebate Internet Subscriber Form

Treatment Authorization Request (TAR) Supplemental Forms

Medical Review/Prolonged Care Assessment Form

DHCS 6013A