​​​DHCS Applications

The following are applications for individuals and providers to participate in DHCS programs:

Medi-Cal

• Provider Enrollment Application Packages Alphabetical by Provider Type
• Medi-Cal Mail-In Application, (multiple languages)

• Health Insurance Premium Payment Application (SP)

California Children's Services (CCS)

The following are applications to enroll children and pregnant women in the Medi-Cal or Healthy Families program

• Application to Determine CCS Program Eligibility (DHCS 4480)
  Alt: Spanish ​​
  
• CCS Special Care Center Directory Update Form (DHCS 4507)

Child Health and Disability Prevention (CHDP) Program

• CHDP Health Assessment Provider Application (DHCS 4490)
• CHDP Health Assessment Provider Program Agreement (DHCS 4491)
• CHDP Laboratory Provider Application (DHCS 4502)
• CDHP Laboratory Provider Program Agreement (DHCS 4503)
• CHDP Pre-Enrollment Application (DHCS 4073)
• CHDP Telecommunications Provider and Biller Application/Agreement (DHCS 4431)
• Newborn Referral Form (MC 330)

Disproportionate Share Hospital Program (DSH)​

• DSH Release of Hospital Confidential Data

Fair Hearing (California Department of Social Services)

• Request for State Hearing before the State Department of Social Services
• Authorized Representative (Form DFA 19)
• Withdrawal/Conditional Withdrawals of Request for Hearing (Form DFA 315)

Hearing Conservation Program

• Application for Registrations as a School Audiometrist (PM 101)

Home and Community-Based Services Branch (HCBS)

• Home and Community-Based Services Branch (HCBS)  

Newborn Hearing Screening Program

• Communication Disorder Center Application (DHCS 4482)
• Outpatient Infant Hearing Screen Provider Application (DHCS 4481)

Substance Use Disorder Compliance Division (SUDCD)

• Licensing and Certification
• Driving-Under-the-Influence (DUI)
• Narcotic Treatment Programs (NTP)