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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.

Billing (CMC, EFT Payments, Hardcopy & POS)

Computer Media Claims (CMC)

Electronic Health Care Claim Payment/Advice Receiver Agreement (ANSI ASC X12N 835 Transaction)

(DHCS 6246)

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. (ACF-001)

Instructions: See "ACF: Required and Optional Fields" for ACF completion instructions.

EFT Payments-Automatic Deposits

EFT Enrollment Authorization EFT Enrollment Authorization PDF (58k)

[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

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)

Community-Based Adult Services (CBAS)

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

Community-Based Adult Services (CBAS) Forms and Instructions

Consent Forms

Consent to Sterilization Consent to Sterilization (53k)

(PM 330 Eng-Sp)

Every Woman Counts

Notice of Privacy Practices

The Notice of Privacy Practices can be downloaded from the DHCS website in English and several other languages.

View the Notice of Privacy Practices

Recipient Application (Provider Use Only)

Recipient Application Recipient Application Form PDF (2436 K)

(DHCS 8699)

Recipient Application Recipient Eligibility Form PDF (1331 K)

(DHCS 8699 (SP))

Recipient Application Recipient Eligibility Form PDF (1521 K)

(DHCS 8699 (CH))

Recipient Application Recipient Eligibility Form PDF (1467 K)

(DHCS 8699 (VI))

Covered Procedures

Breast Only Primary Care Provider Covered Procedures

(DHCS 8471)

Breast and Cervical Primary Care Provider Covered Procedures

(DHCS 8472)

Referral Provider Covered Procedures Referral Provider Reimbursable Procedures PDF (568k)

(DHCS 8473)

Provider Data Request Form

Enrollment and Recipient Cycles Data Request Form

(DHCS 8646) [Fillable]

Family PACT

The following forms are available for download on the Provider Enrollment page of the Family PACT website.

Download Family PACT provider enrollment forms

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.

Download Client Eligibility Certification and Retroactive Eligibility Certification forms

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))

Facilities & Hospitals

Distinct-Part Nursing Facilities (DP/NF)

Call List for NF Placement Call List for NF Placement pdf (17k)

Family Certification Family Certification Word Doc (99k)

(DHS 6223)

Medical Certification Medical Certification Word Doc (98k)

(DHS 6224)

Hospice

Hospice General Inpatient Information Sheet

(DHS 6194)

Instructions

Inpatient Non-Contract Hospital

Revenue Rate Change Request Revenue Rate Change Request PDF (298k)

(DHCS 6004)

Quality Assurance Fee (QAF)

Quarterly Payment Designated Intermediate Care Facility (DICF) QAF Quarterly Payment DICF Word (58k)

(DHCS 9085)

Annual Report Designated Intermediate Care Facility (DICF) QAF Annual Report DICF (49k)

(DHCS 9102)

Hospital Presumptive Eligibilty (HPE)

Hospital Presumptive Eligibility (HPE) Program Provider Election Form and Agreement

(DHCS 7012)

Hospital Presumptive Eligibility (HPE) Provider Intake Advisor Verification Form

(DHCS 7011)

Hospital Presumptive Eligibility (HPE): Provider Enrollment Instructions

Hospital Presumptive Eligibility (HPE) Provider Enrollment Checklist

Medi-Cal Order Form Medi-Cal Order Form MC 0026 (11/18)

(MC 0026)

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

Qualified Provider Application for Presumptive Eligibility Participation

(MC 311)

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet

(MC 264)

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Armenian)

(MC 264 (AM))

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Arabic)

(MC 264 (AR))

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Cambodian)

(MC 264 (CA))

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Chinese)

(MC 264 (CH))

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Farsi)

(MC 264 (FA))

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Hmong)

(MC 264 (HM))

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Korean)

(MC 264 (KR))

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Russian)

(MC 264 (RS))

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Spanish)

(MC 264 (SP))

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Tagalog)

(MC 264 (TG))

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Vietnamese)

(MC 264 (VT))

Medi-Cal Order Form Medi-Cal Order Form MC 0026 (11/18)

(MC 0026)

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)

Applications

For more information: Provider Enrollment Division (PED)

"Elect to Participate" Indian Health Services Memorandum of Agreement (IHS/MOA) Application (New 9/17)

(DHCS 7108) [Fillable]

Medi-Cal Disclosure Statement (Rev 2/17)

(DHCS 6207) [Fillable]

Medi-Cal Specialty Pharmacy Provider Application (New 4/10)

(MC 3155) [Fillable]

Medi-Cal Provider Agreement (Rev 2/17)

(DHCS 6208) [Fillable]

Medi-Cal Provider Application (Rev 2/17)

(DHCS 6204) [Fillable]

Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (Rev 5/17)

(DHCS 6216) [Fillable]

Medi-Cal Supplemental Changes (Rev 2/18)

(DHCS 6209) [Fillable]

Medi-Cal Provider Agreement - Institutional Provider (Rev 7/17) Medi-Cal Provider Agreement (Institutional Provider) (Rev 7/17) PDF (444 K)

(DHCS 9098) [Fillable]

General

Medi-Cal Provider Number Verification Form

2017-2018 Certification of Compliance

(MC 0805) [Fillable]

Successor Liability with Joint and Several Liability Agreement (Rev 5/17)

(DHCS 6217) [Fillable]

Request for Live Scan Service Now Available

(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.