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Update to the Incontinence Supplies Prescription Form (DHCS 6187)

November 26, 2019

Effective on or after February 1, 2020, the revised Incontinence Supplies Prescription Form (DHCS 6187), retitled Incontinence Supplies Medical Necessity Certification, must accompany all Treatment Authorization Requests (TARs) submitted for approval to bill incontinence supplies directly to Medi-Cal. A provider-generated form and older versions of the DHCS 6187 form are no longer accepted on or after February 1, 2020. Authorization requests are deferred and returned to the provider if the DHCS 6187 form is incomplete or not included with the TAR.

The DHCS 6187 form can be found on the Forms page of the Medi-Cal website. Instructions for completing the form are located on page 4 of the DHCS 6187 form.