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.

The following forms are available for download on the Community-Based Adult Services (CBAS) Forms and Instructions website.  

Notice of Privacy Practices
The Notice of Privacy Practices can be downloaded from the DHCS website in English and several other languages.  
Recipient Application (Provider Use Only)
Recipient ApplicationRecipient Application Form PDF (2436 K) (DHCS 8699)  
Recipient ApplicationRecipient Eligibility Form PDF (1331 K) (DHCS 8699 (SP))  
Recipient ApplicationRecipient Eligibility Form PDF (1521 K) (DHCS 8699 (CH))  
Recipient ApplicationRecipient Eligibility Form PDF (1467 K) (DHCS 8699 (VI))  
Provider Data Request Form

The following forms are available for download on the Provider Enrollment page of the Family PACT website.  
Application to Participate in the Family PACT Program (DHCS 4468)  
Family PACT Program Provider Agreement (DHCS 4469)  
The following forms are available for download on the Forms page of the Family PACT website.  
Health Access Programs Family PACT Program Retroactive Eligibility Certification (DHCS 4001)  
Health Access Programs Family PACT Program Retroactive Eligibility Certification (Spanish) (DHCS 4001 (SP))  
Health Access Programs Family PACT Program Client Eligibility Certification (DHCS 4461)  
Health Access Programs Family PACT Program Client Eligibility Certification (Spanish) (DHCS 4461 (SP))  

Distinct-Part Nursing Facilities (DP/NF)
Family CertificationFamily Certification Word Doc (99k) (DHS 6223)  
Medical CertificationMedical Certification Word Doc (98k) (DHS 6224)  
Inpatient Non-Contract Hospital

Out-of-State Provider
Please contact the Out-of-State Provider Unit for requirements and more information.
General
Request for Live Scan Service Now AvailableRequest for Live Scan (BCIA 8016)  [Fillable]
  • Forms for Applicant Agencies: Click on the "Instructions for Live Scan Request Forms" link on this page to view Guidelines for Completing the BCIA 8016
Note for BCIA 8016: Required for all providers designated by DHCS as "high risk." The Department of Justice website includes additional information on fingerprint background checks and live scan sites.