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References
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)
CMC Enrollment Procedures
CMC Enrollment Checklist
837 Claim Attachment Guidelines for Providers and Vendors
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
[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 Electronic Point of Service (POS) Network/Internet Agreement
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
(PM 330 Eng-Sp)
Tips and Reminders
Example
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
(DHCS 8699)
Recipient Application
(DHCS 8699 (CH))
Recipient Application
(DHCS 8699 (HIN))
Recipient Application
(DHCS 8699 (PUN))
Recipient Application
(DHCS 8699 (SP))
Recipient Application
(DHCS 8699 (UKR))
Recipient Application
(DHCS 8699 (VI))
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
Family Certification
(DHS 6223)
Medical Certification
(DHS 6224)
Hospice
Hospice General Inpatient Information Sheet
(DHS 6194)
Instructions
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)
Hospital Presumptive Eligibility (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
(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
(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 (Rev 6/21)
(DHCS 7108)
[Fillable]
Medi-Cal Disclosure Statement (Rev 2/17)
(DHCS 6207)
[Fillable]
Medi-Cal Specialty Pharmacy Provider Application (Rev 1/22)
(MC 3155)
[Fillable]
Medi-Cal Provider Agreement (Rev 8/21)
(DHCS 6208)
[Fillable]
Medi-Cal Provider Application (Rev 2/17)
(DHCS 6204)
[Fillable]
Medi-Cal Supplemental Changes (Rev 11/21)
(DHCS 6209)
[Fillable]
Medi-Cal Provider Agreement - Institutional Provider (Rev 7/17)
(DHCS 9098)
[Fillable]
General
Medi-Cal Provider Number Verification Form
2019-2020 Certification of Compliance
(MC 0805)
[Fillable]
Successor Liability with Joint and Several Liability Agreement (Rev 11/21)
(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.
View Fingerprint Background Checks page
Request for Exemption from Mandatory Electronic Fingerprint Submission Requirement
(CJIS 9004)
[Fillable]
Supplemental Claims Payment Information (SCPI)
For information and to enroll in SCPI, please contact the California MMIS Fiscal Intermediary by either calling (916) 612-5378
or (916) 601-7402, or emailing SCPI@us.ibm.com.
Supplies, Injections & DUR
Drug Rebate Internet Subscriber Form
Treatment Authorization Request (TAR) Supplemental Forms
TAR 3 Attachment Form
[Fillable]
TAR Update Transmittal Form
[Fillable]
TAR Update Transmittal Form 18-3
[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)
Certificate of Medical Necessity for a Manual Wheelchair, Standard or Custom
(DHCS 6181A)
[Fillable]
Certificate of Medical Necessity for a Motorized Wheelchair, Standard or Custom
(DHCS 6181B)
[Fillable]
Certificate of Medical Necessity for a Power Operated Vehicle (POV) AKA Scooter, Standard or Bariatric
(DHCS 6181C)
[Fillable]
Incontinence Supplies Medical Necessity Certification
(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)
Preadmission Screening Resident Review (PASRR) Enrollment
Transmittal Form
(MC 3020)
[Fillable]
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)
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