Welcome to the Department of Health Care Services Welcome to Medi-Cal Welcome to the Department of Health Care Services

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.

Click the PDF PDF, Word Word Doc or Excel Excel icon to the left of the form name to view or download the form. The PDF forms require Adobe Reader. If you need to install or upgrade to the latest version, visit the Web Tool Box.


Billing (CMC, EFT Payments, Hardcopy & POS)

Computer Media Claims (CMC)
CHDP Telecommunications Provider and Biller Application/Agreement pdf (255k) CHDP Telecommunications Provider and Biller Application/Agreement   [Fillable] DHCS 4431
Electronic Health Care Claim Payment/Advice Receiver Agreement (ANSI ASC X12N 835 Transaction) Word Doc (79k) Electronic Health Care Claim Payment/Advice Receiver Agreement (ANSI ASC X12N 835 Transaction)   DHCS 6246
Medi-Cal Telecommunications Provider and Biller Application/Agreement Word Doc (64k) Medi-Cal Telecommunications Provider and Biller Application/Agreement   DHCS 6153
Attachments: Call the Telephone Service Center (TSC) 1-800-541-5555 to order an Attachment Control Form (ACF) form.  
Instructions: See "ACF: Required and Optional Fields" for ACF completion instructions.
ACF-001
EFT Payments-Automatic Deposits
EFT Enrollment Authorization PDF (58k) EFT Enrollment Authorization   [Fillable]
Hardcopy
Biller: Medi-Cal Hardcopy Biller Application Agreement Word Doc (21k) Biller: Medi-Cal Hardcopy Biller Application Agreement  
Provider: Medi-Cal Hardcopy Biller Notification Form Word Doc (21k) Provider: Medi-Cal Hardcopy Biller Notification Form  
Point of Service (POS) Network
Automated Eligibility Verification System (AEVS) Response Log Word Doc (33k) Automated Eligibility Verification System (AEVS) Response Log  
Medi-Cal Eligibility Verification Enrollment Form Word Doc (23k) Medi-Cal Eligibility Verification Enrollment Form  
Medi-Cal Point of Service (POS) Network/Internet Agreement Word Doc (39k) Medi-Cal Point of Service (POS) Network/Internet Agreement  
Point of Service (POS) Device Usage Agreement Word Doc (25k) Point of Service (POS) Device Usage Agreement  


California Children's Services (CCS)

CCS Program Individual Provider Paneling Application for Allied Health Care Professionals PDF (461k) CCS Program Individual Provider Paneling Application for Allied Health Care Professionals   DHCS 4515
CCS Program Individual Provider Paneling Application for Physicians and Podiatrists PDF (235k) CCS Program Individual Provider Paneling Application for Physicians and Podiatrists   DHCS 4514
CCS/GHPP Discharge Planning Service Authorization Request (SAR) PDF (260k) CCS/GHPP Discharge Planning Service Authorization Request (SAR)   DHCS 4489
Established CCS/GHPP Client Service Authorization Request (SAR) PDF (197k) Established CCS/GHPP Client Service Authorization Request (SAR)   DHCS 4509
New Referral CCS/GHPP Client Service Authorization Request (SAR) PDF (207k) New Referral CCS/GHPP Client Service Authorization Request (SAR)   DHS 4488


Community-Based Adult Services (CBAS)

Community-Based Adult Services Individual Plan of Care pdf (129k) Community-Based Adult Services Individual Plan of Care   DHCS 0020


Consent Forms

Consent to Sterilization (53k) Consent to Sterilization   PM 330 Eng-Sp


Every Woman Counts

Consent to Participate in Program (Provider Use Only)
Consent to Participate in Program and Privacy Statement (English) PDF (37k) Consent to Participate in Program(English)   DCHS 8478
Note: The Consent to Participate in Program will be available in other languages at a later date.  
Notice of Privacy Practices
The Notice of Privacy Practices can be downloaded from the DHCS website in English and several other languages.  
Recipient Eligibility (Provider Use Only)
Recipient Eligibility Form PDF (18 K) Recipient Eligibility Form   DHCS 8699
Recipient Eligibility Form PDF (345 K) Recipient Eligibility Form   DHCS 8699 (SP)
Breast and Cervical Data Entry Worksheets & Instructions
Breast Cancer Screening Cycle Data Worksheet PDF (84k) Breast Cancer Screening Cycle Data Worksheet   DHCS 8709
Breast Cancer Screening Cycle Data Instructions PDF (27k) Breast Cancer Screening Cycle Data Instructions   DHCS 8709
Cervical Cancer Screening Cycle Data Worksheet PDF (43k) Cervical Cancer Screening Cycle Data Worksheet   DHCS 8710
Cervical Cancer Screening Cycle Data Worksheet Instructions PDF (27k) Cervical Cancer Screening Cycle Data Instructions   DHCS 8710
Covered Procedures
Breast Only Primary Care Provider Covered Procedures (under revision)   DHCS 8471
Breast & Cervical Primary Care Provider Covered Procedures (under revision)   DHCS 8472
Referral Provider Covered Procedures (under revision)   DHCS 8473


Family PACT

The following forms are available for download on the Provider Enrollment Forms page of the Family PACT website.  
Application to Participate in the Family PACT Program   DHCS 4468
Family PACT Program Disclosure Statement   DHCS 4471
Family PACT Program Practitioner Participation Agreement   DHCS 4470
Family PACT Program Provider Agreement   DHCS 4469
 
Health Access Programs Family PACT Program Retroactive Client Eligibility Certification (93k) Health Access Programs Family PACT Program Retroactive Client Eligibility Certification   DHCS 4001
Health Access Programs Family PACT Program Retroactive Client Eligibility Certification (Spanish) pdf(73k) Health Access Programs Family PACT Program Retroactive Client Eligibility Certification (Spanish)   CDPH 4001 (SP)
Health Access Programs Family PACT Program Client Eligibility Certification (43k) Health Access Programs Family PACT Program Client Eligibility Certification   DHCS 4461
Health Access Programs Family PACT Program Client Eligibility Certification (Spanish) pdf(70k) Health Access Programs Family PACT Program Client Eligibility Certification (Spanish)   CDPH 4461 (SP)


Facilities & Hospitals

Distinct-Part Nursing Facilities (DP/NF)
Call List for NF Placement Word Doc (107) Call List for NF Placement  
Family Certification Word Doc (99k) Family Certification   DHS 6223
Medical Certification Word Doc (98k) Medical Certification   DHS 6224
Medi-Cal Information Sheet for Hospital-Based Nursing Facility Patients (English) Word Doc (120k) Medi-Cal Information Sheet for Hospital-Based Nursing Facility Patients (English)  
Medi-Cal Information Sheet for Hospital-Based Nursing Facility Patients (Spanish) Word Doc (126k) Medi-Cal Information Sheet for Hospital-Based Nursing Facility Patients (Spanish)  
Hospice
Hospice General Inpatient Information Sheet Word Doc (28k) Hospice General Inpatient Information Sheet   DHS 6194
Inpatient Non-Contract Hospital
Revenue Rate Change Request PDF (298k) Revenue Rate Change Request   DHCS 6004
Quality Assurance Fee (QAF)
QAF Quarterly Payment DICF Word (58k) Quarterly Payment Designated Intermediate Care Facility (DICF)   DHCS 9085
QAF Annual Report DICF (49k) Annual Report Designated Intermediate Care Facility (DICF)   DHCS 9102


Hospital Presumptive Eligibilty (PE)

Hospital Presumptive Eligibility (PE) Program Provider Election Form and Agreement PDF (132k) Hospital Presumptive Eligibility (PE) Program Provider Election Form and Agreement   DHCS 7012
Hospital Presumptive Eligibility (PE): Provider Enrollment Instructions (55k) Hospital Presumptive Eligibility (PE): Provider Enrollment Instructions  
Hospital Presumptive Eligibility (PE) Provider Enrollment Checklist (31k) Hospital Presumptive Eligibility (PE) Provider Enrollment Checklist  


Medi-Cal Tuberculosis Program

Medi-Cal Tuberculosis Program Application (Spanish) PDF (141k) Medi-Cal Tuberculosis Program Application (Spanish)   MC 274 TB (SP)
Medi-Cal Tuberculosis Program Application PDF (139k) Medi-Cal Tuberculosis Program Application   MC 274 TB


Presumptive Eligibility for Pregnant Women

Presumptive Eligibility
Presumptive Eligibility Forms Order Word Doc (24k) Presumptive Eligibility Forms Order   MC 285
Qualified Provider Application for Presumptive Eligibility Participation and Presumptive Eligibility Qualified Provider Responsibilities and Agreement Word Doc (47k) Qualified Provider Application for Presumptive Eligibility Participation and Presumptive Eligibility Qualified Provider Responsibilities and Agreement   MC 311
Statement of California Residency (240k) Statement of California Residency   MC 263-SR
Statement of California Residency (Spanish) pdf (313k) Statement of California Residency (Spanish)   MC 263-SR (SP)
Presumptive Eligibility Patient Fact Sheet pdf (16k) Presumptive Eligibility Patient Fact Sheet   MC 264
Presumptive Eligibility Patient Fact Sheet (Armenian) pdf (78k) Presumptive Eligibility Patient Fact Sheet (Armenian)   MC 264 (AM)
Presumptive Eligibility Patient Fact Sheet (Arabic) pdf (116k) Presumptive Eligibility Patient Fact Sheet (Arabic)   MC 264 (AR)
Presumptive Eligibility Patient Fact Sheet (Cambodian) pdf (140k) Presumptive Eligibility Patient Fact Sheet (Cambodian)   MC 264 (CA)
Presumptive Eligibility Patient Fact Sheet (Chinese) pdf (163k) Presumptive Eligibility Patient Fact Sheet (Chinese)   MC 264 (CH)
Presumptive Eligibility Patient Fact Sheet (Farsi) pdf (138k) Presumptive Eligibility Patient Fact Sheet (Farsi)   MC 264 (FA)
Presumptive Eligibility Patient Fact Sheet (Hmong) pdf (97k) Presumptive Eligibility Patient Fact Sheet (Hmong)   MC 264 (HM)
Presumptive Eligibility Patient Fact Sheet (Korean) pdf (179k) Presumptive Eligibility Patient Fact Sheet (Korean)   MC 264 (KR)
Presumptive Eligibility Patient Fact Sheet (Russian) pdf (139k) Presumptive Eligibility Patient Fact Sheet (Russian)   MC 264 (RS)
Presumptive Eligibility Patient Fact Sheet (Spanish) pdf (90k) Presumptive Eligibility Patient Fact Sheet (Spanish)   MC 264 (SP)
Presumptive Eligibility Patient Fact Sheet (Tagalog) pdf (100k) Presumptive Eligibility Patient Fact Sheet (Tagalog)   MC 264 (TG)
Presumptive Eligibility Patient Fact Sheet (Vietnamese) pdf (80k) Presumptive Eligibility Patient Fact Sheet (Vietnamese)   MC 264 (VT)
Patient Directions for Presumptive Eligibility Application pdf (14k) Patient Directions for Presumptive Eligibility Application   MC 265
Patient Directions for Presumptive Eligibility Application (Spanish) pdf (43k) Patient Directions for Presumptive Eligibility Application (Spanish)   MC 265 (SP)
Directions to Apply for Medi-Cal Directions to Apply for Medi-Cal   MC 266
Explanation of Ineligibility for Presumptive Eligibility pdf (32k) Explanation of Ineligibility for Presumptive Eligibility   MC 267
Explanation of Ineligibility for Presumptive Eligibility (Spanish) pdf (71k) Explanation of Ineligibility for Presumptive Eligibility (Spanish)   MC 267(SP)
Weekly Presumptive Eligibility (PE) Enrollment Summary Weekly Presumptive Eligibility (PE) Enrollment Summary  [Fillable] MC 283
Presumptive Eligibility Provider Fact Sheet 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 PDF (212K) Out-of-State Provider Express Enrollment   MC 4603
Crossover Only Providers
Crossover Only Provider Form PDF (140K) Crossover Only Provider Form   MC 0804
Applications
Drug Medi-Cal Provider Agreement (new 9/14) PDF (296 K) Drug Medi-Cal Provider Agreement (new 9/14)   [Fillable] DHCS 6009
Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement For Physician and Non-physician Practitioners (revised 7/14) PDF (296 K) Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement For Physician and Non-physician Practitioners (revised 7/14)  [Fillable] DHCS 6219
Medi-Cal Clinical Medical Laboratory Application (revised 1/13) PDF (527 K) Medi-Cal Clinical Medical Laboratory Application (revised 1/13)   [Fillable] DHCS 6204
Medi-Cal Clinic-Based Certified Nurse Midwife Application (revised 1/13) PDF (690 K) Medi-Cal Clinic-Based Certified Nurse Midwife Application (revised 1/13)  [Fillable] DHCS 6204
Medi-Cal Disclosure Statement (revised 7/14) PDF (1,096 K) Medi-Cal Disclosure Statement (revised 7/14)   [Fillable] DHCS 6207
Medi-Cal Durable Medical Equipment Provider Application (revised 5/14) PDF (752 K) Medi-Cal Durable Medical Equipment Provider Application (revised 5/14)  [Fillable] DHCS 6201
Medi-Cal Medical Transportation Provider Application (revised 1/13) PDF (726 K) Medi-Cal Medical Transportation Provider Application (revised 1/13)   [Fillable] DHCS 6206
Medi-Cal Nonphysician Medical Practitioner and Licensed Midwife Application (revised 1/13) PDF (646 K) Medi-Cal Nonphysician Medical Practitioner and Licensed Midwife Application (revised 1/13)  [Fillable] DHCS 6248
Medi-Cal Orthotics and Prosthetics Provider Application (revised 1/13) PDF (616 K) Medi-Cal Orthotics and Prosthetics Provider Application (revised 1/13)   [Fillable] DHCS 6202
Medi-Cal Specialty Pharmacy Provider Application (revised 4/10) PDF (36 K) Medi-Cal Specialty Pharmacy Provider Application (new 4/10)  [Fillable] MC 3155
Medi-Cal Pharmacy Provider Application (revised 5/14) PDF (767 K) Medi-Cal Pharmacy Provider Application (revised 5/14)   [Fillable] DHCS 6205
Medi-Cal Physician Application/Agreement (revised 1/13) PDF (705 K) Medi-Cal Physician Application/Agreement (revised 1/13)  [Fillable] DHCS 6210
Medi-Cal Provider Agreement (revised 11/11) PDF (339 K) Medi-Cal Provider Agreement (revised 11/11)   [Fillable] DHCS 6208
Medi-Cal Provider Application (revised 1/13) PDF (515 K) Medi-Cal Provider Application (revised 1/13)  [Fillable] DHCS 6204
Medi-Cal Provider Group Application (revised 1/13) PDF (640 K) Medi-Cal Provider Group Application (revised 1/13)   [Fillable] DHCS 6203
Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (revised 7/14) PDF (509 K) Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (revised 7/14)  [Fillable] DHCS 6216
Medi-Cal Supplemental Changes (revised 1/13) PDF (828 KB) Medi-Cal Supplemental Changes (revised 1/13)   [Fillable] DHCS 6209
Medi-Cal Hospital-Based Physician Application/Disclosure Statement/Agreement (revised 7/08) PDF (728 K) Medi-Cal Hospital-Based Physician Application/Disclosure Statement/Agreement (new 7/08)  [Fillable] DHCS 9095
Medi-Cal Change Of Location Form For Individual Physician Or Individual Dentist Practices Relocating Within The Same County  (new 1/11) PDF (338 K) Medi-Cal Change Of Location Form For Individual Physician Or Individual Dentist Practices Relocating Within The Same County (new 1/11)   [Fillable] DHCS 9096
Medi-Cal Provider Agreement (Institutional Provider) (new 8/08) PDF (60 K) Medi-Cal Provider Agreement - Institutional Provider (new 6/10)  [Fillable] DHCS 9098
Facilities Only
"Pay-To" Address Change NotificationWord pdf (88k) "Pay-To" Address Change Notification   DHCS 6129
General
Medi-Cal Provider Number Verification Form PDF (9k) Medi-Cal Provider Number Verification Form  
Medi-Cal Certification of Compliance PDF (192 k) Medi-Cal Certification of Compliance  [Fillable] MC 0805
Medi-Cal Usual and Customary Rates Report (58 KB) Medi-Cal Usual and Customary Rates Report   MC 3152
Successor Liability with Joint and Several Liability Agreement (revised 2/08) PDF (268 K) Successor Liability with Joint and Several Liability Agreement (revised 2/08)  [Fillable] DHCS 6217


Provider-Preventable Conditions (PPCs)

Medi-Cal Provider-Preventable Conditions Reporting Form PDF (115k) Medi-Cal Provider-Preventable Conditions Reporting Form   [Fillable] DHCS 7107


Supplemental Claims Payment Information (SCPI)

Supplemental Claims Payment Information Enrollment (Provider) PDF (652k) Supplemental Claims Payment Information Enrollment (Provider)   [Fillable]
Supplemental Claims Payment Information Enrollment (Vendor) PDF (77k) Supplemental Claims Payment Information Enrollment (Vendor)  [Fillable]
Supplemental Claims Payment Information Services Agreement PDF (118k) Supplemental Claims Payment Information Services Agreement   [Fillable]
Provider Release Authorization PDF (451k) Provider Release Authorization  [Fillable]


Supplies, Injections & DUR

Incontinence Supplies Prescription Form Word Doc (46k) Incontinence Supplies Prescription Form  
Drug Rebate Internet Subscriber Form PDF (37k) Drug Rebate Internet Subscriber Form  


Treatment Authorization Request (TAR) Supplemental Forms

TAR 3 Attachment Form (858 KB) TAR 3 Attachment Form   [Fillable]
T18-3 TAR Update Transmittal Form (532 KB) TAR Update Transmittal Form 18-3  [Fillable]
Certification for Special Treatment Program Services (PDF) (48 KB) Certification for Special Treatment Program Services   HS 231
Certificate of Medical Necessity for All Durable Medical Equipment (DME)(Except Wheelchairs and Scooters (PDF) (936 KB) Certificate of Medical Necessity for All Durable Medical Equipment (DME)(Except Wheelchairs and Scooters)   DHCS 6181
Incontinence Supplies Prescription Form (PDF) (61 KB) Incontinence Supplies Prescription Form   DHCS 6187
Information for Authorization/Reauthorization of Subacute Care Services - Adult Subacute Program (PDF) (75 KB) Information for Authorization/Reauthorization of Subacute Care Services - Adult Subacute Program   DHCS 6200A
Information for Authorization/Reauthorization of Subacute Care Services- Pediatric Subacute Program (PDF) (86 KB) Information for Authorization/Reauthorization of Subacute Care Services- Pediatric Subacute Program   DHCS 6200
Medical Justification for Therapy Treatment Plan (PDF) (103 KB) Medical Justification for Therapy Treatment Plan   DHCS 6183
Medical Review / Prolonged Care Assessment Form Word Doc (111 KB) Medical Review/Prolonged Care Assessment Form   DHCS 6013A
Non-Emergency Medical Transportation (NEMT) Required Justification (14 KB) Non-Emergency Medical Transportation (NEMT) Required Justification   DHCS 6182
PAS/PASARR Level I Screening Document (66 KB) PAS/PASARR Level I Screening Document   DHCS 6170
Transmittal Form (25 KB) Transmittal Form   MC 3020
Certificate of Medical Necessity for Apnea Monitors (40KB) Certificate of Medical Necessity for Apnea Monitors   MC 4600
Certificate of Medical Necessity for Nebulizers (41KB) Certificate of Medical Necessity for Nebulizers   MC 4601
Certificate of Medical Necessity for Oxygen (43KB) Certificate of Medical Necessity for Oxygen   MC 4602