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Billing (CMC, EFT Payments, Hardcopy & POS)

Computer Media Claims (CMC)
	CHDP Telecommunications Provider and Biller Application/Agreement   [Fillable]	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
	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   [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

Every Woman Counts

Consent to Participate in Program
	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 (English Form) can be downloaded from the DHCS website.   Notice of Privacy Practices
	Note: The Notice of Privacy Practices will be available in other languages at a later date.
Recipient Eligibility
	Recipient Eligibility Form	DHCS 8699
	Recipient Eligibility Form	DHCS 8699 (SP)
Breast and Cervical Data Entry Worksheets & Instructions
	Breast Cancer Screening Cycle Data Worksheet	DHCS 8709
	Breast Cancer Screening Cycle Data Instructions	DHCS 8709
	Cervical Cancer Screening Cycle Data Worksheet	DHCS 8710
	Cervical Cancer Screening Cycle Data Instructions	DHCS 8710
Covered Procedures
	Breast & Cervical Primary Care Provider Covered Procedures	DHCS 8472
	Breast Only Primary Care Provider Covered Procedures	DHCS 8471
	Referral Provider Covered Procedures	DHCS 8473

Community-Based Adult Services (CBAS)

Community-Based Adult Services Individual Plan of Care

DHCS 0020

Consent Forms

Consent to Sterilization   Tips and Reminders Example

PM 330 Eng-Sp

Family PACT

	Application to Participate in the Family PACT Program	CDPH 4468
	Family PACT Program Disclosure Statement	CDPH 4471
	Family PACT Program Practitioner Participation Agreement	CDPH 4470
	Family PACT Program Provider Agreement	CDPH 4469
	Family PACT Retroactive Client Eligibility Certification	CDPH 4001
	Family PACT Retroactive Client Eligibility Certification (Spanish)	CDPH 4001 (SP)
	Family PACT Program Client Eligibility Certification	CDPH 4661
	Family PACT Program Client Eligibility Certification (Spanish)	CDPH 4661 (SP)

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	DHCS 6004
Quality Assurance Fee (QAF)
	Quarterly Payment Designated Intermediate Care Facility (DICF)	DHCS 9085
	Annual Report Designated Intermediate Care Facility (DICF)	DHCS 9102

Medi-Cal Tuberculosis Program

	Medi-Cal Tuberculosis Program Application (Spanish)	MC 274 TB (SP)
	Medi-Cal Tuberculosis Program Application	MC 274 TB

Presumptive Eligibility for Pregnant Women

Presumptive Eligibility
	Presumptive Eligibility Forms Order	MC 285
	Qualified Provider Application for Presumptive Eligibility Participation and Presumptive Eligibility Qualified Provider Responsibilities and Agreement	MC 311
	Statement of California Residency	MC 263-SR
	Statement of California Residency (Spanish)	MC 263-SR (SP)
	Presumptive Eligibility Patient Fact Sheet	MC 264
	Presumptive Eligibility Patient Fact Sheet (Armenian)	MC 264 (AM)
	Presumptive Eligibility Patient Fact Sheet (Arabic)	MC 264 (AR)
	Presumptive Eligibility Patient Fact Sheet (Cambodian)	MC 264 (CA)
	Presumptive Eligibility Patient Fact Sheet (Chinese)	MC 264 (CH)
	Presumptive Eligibility Patient Fact Sheet (Farsi)	MC 264 (FA)
	Presumptive Eligibility Patient Fact Sheet (Hmong)	MC 264 (HM)
	Presumptive Eligibility Patient Fact Sheet (Korean)	MC 264 (KR)
	Presumptive Eligibility Patient Fact Sheet (Russian)	MC 264 (RS)
	Presumptive Eligibility Patient Fact Sheet (Spanish)	MC 264 (SP)
	Presumptive Eligibility Patient Fact Sheet (Tagalog)	MC 264 (TG)
	Presumptive Eligibility Patient Fact Sheet (Vietnamese)	MC 264 (VT)
	Patient Directions for Presumptive Eligibility Application	MC 265
	Patient Directions for Presumptive Eligibility Application (Spanish)	MC 265 (SP)
	Directions to Apply for Medi-Cal	MC 266
	Explanation of Ineligibility for Presumptive Eligibility	MC 267
	Explanation of Ineligibility for Presumptive Eligibility (Spanish)	MC 267(SP)
	Weekly Presumptive Eligibility (PE) Enrollment Summary  [Fillable]	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	MC 4603
Crossover Only Providers
	Crossover Only Provider Form	MC 0804
Applications For more information: Provider Enrollment Division (PED)
	Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement For Physician and Non-physician Practitioners (revised 1/13)   [Fillable]	DHCS 6219
	Medi-Cal Clinical Medical Laboratory Application (revised 1/13)  [Fillable]	DHCS 6204
	Medi-Cal Clinic-Based Certified Nurse Midwife Application (revised 1/13)   [Fillable]	DHCS 6204
	Medi-Cal Disclosure Statement (revised 11/11)  [Fillable]	DHCS 6207
	Medi-Cal Durable Medical Equipment Provider Application (revised 1/13)   [Fillable]	DHCS 6201
	Medi-Cal Medical Transportation Provider Application (revised 1/13)  [Fillable]	DHCS 6206
	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)  [Fillable]	DHCS 6202
	Medi-Cal Specialty Pharmacy Provider Application (new 4/10)   [Fillable]	MC 3155
	Medi-Cal Pharmacy Provider Application (revised 1/13)  [Fillable]	DHCS 6205
	Medi-Cal Physician Application/Agreement (revised 1/13)   [Fillable]	DHCS 6210
	Medi-Cal Provider Agreement (revised 11/11)  [Fillable]	DHCS 6208
	Medi-Cal Provider Application (revised 1/13)   [Fillable]	DHCS 6204
	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 1/13)   [Fillable]	DHCS 6216
	Medi-Cal Supplemental Changes (revised 1/13)  [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 Or Individual Dentist Practices Relocating Within The Same County (new 1/11)  [Fillable]	DHCS 9096
	Medi-Cal Provider Agreement - Institutional Provider (new 6/10)   [Fillable]	DHCS 9098
Facilities Only
	"Pay-To" Address Change Notification	DHCS 6129
General
	Medi-Cal Provider Number Verification Form
	Medi-Cal Certification of Compliance  [Fillable]	MC 0805
	Medi-Cal Usual and Customary Rates Report	MC 3152
	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

Provider-Preventable Conditions (PPCs)

Medi-Cal Provider-Preventable Conditions Reporting Form   [Fillable]

DHCS 7107

Supplemental Claims Payment Information (SCPI)

	Supplemental Claims Payment Information Enrollment (Provider)   [Fillable]
	Supplemental Claims Payment Information Enrollment (Vendor)  [Fillable]
	Supplemental Claims Payment Information Services Agreement   [Fillable]
	Provider Release Authorization  [Fillable]

Supplies, Injections & DUR

	Incontinence Supplies Prescription Form   Instructions
	Drug Rebate Internet Subscriber Form

Treatment Authorization Request (TAR) Supplemental Forms

	TAR 3 Attachment Form   [Fillable]
	Certification for Special Treatment Program Services	HS 231
	Certificate of Medical Necessity for All Durable Medical Equipment (DME)(Except Wheelchairs and Scooters)	DHCS 6181
	Incontinence Supplies Prescription Form	DHCS 6187
	Information for Authorization/Reauthorization of Subacute Care Services - Adult Subacute Program	DHCS 6200A
	Information for Authorization/Reauthorization of Subacute Care Services- Pediatric Subacute Program	DHCS 6200
	Medical Justification for Therapy Treatment Plan	DHCS 6183
	Medical Review/Prolonged Care Assessment Form	DHCS 6013A
	Non-Emergency Medical Transportation (NEMT) Required Justification	DHCS 6182
	PAS/PASARR Level I Screening Document	DHCS 6170
	Transmittal Form	MC 3020
	Certificate of Medical Necessity for Apnea Monitors	MC 4600
	Certificate of Medical Necessity for Nebulizers	MC 4601
	Certificate of Medical Necessity for Oxygen	MC 4602