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Drug Medi-Cal Treatment Program Forms
MC 5120AD - Vendor Approver Certification
(PDF)
MC 5121AD - County-Direct Provider Approver Certification
(PDF)
MC 5123AD - DHCS Employee Approver Certification
(PDF)
MC 5131AD - County-Direct Provider User Cancellation
(PDF)
MC 5312: Drug Medi-Cal (DMC) Services Claim for Reimbursement of County Administrative Expenses
(Excel)
DHCS 5311 Form - DMC-ODS Claim for Reimbursement of Quality Assurance/Utilization Review (QA/UR) Costs
(Excel)
DHCS 5311 Form - DMC-ODS Claim for Reimbursement of Quality Assurance/Utilization Review (QA/UR) Costs Starting 7/1/2022 (Excel)
DHCS 6065A Form - Good Cause Certification
(PDF)
DHCS 6065A Instructions - Good Cause Certification
(PDF)
DHCS 6065B Form - Good Cause Certification
(PDF)
DHCS 6065B Instructions - Good Cause Certification
(PDF)
DHCS 6700 Form - Multiple Billing Override Certification
(PDF)
DHCS 6700 Instructions - Multiple Billing Override Certification Instructions
(PDF)
DHCS 100185 Form - DMC Claim Submission Certification - Direct Contract Provider
(PDF)
DHCS 100185 Instructions - DMC Claim Submission Certification - Direct Contract Provider
(PDF)
DHCS 100186 Form - DMC Claim Submission Certification - County Contracted Provider
(PDF)
DHCS 100186 Instructions - DMC Claim Submission Certification - County Contracted Provider
(PDF)
DHCS 100187 Form - DMC Claim Submission Certification - County Operated Provider Form
(PDF)
DHCS 100224 - Drug Medi-Cal Certification for Federal Reimbursement
(PDF)
DHCS 8049 Form - County Certification of Compliance (
PDF) Revised 02-21
DHCS 8049 Instructions - County Certification of Compliance
(PDF)
DHCS 5260 Form - SUDCRS Approver Form
(PDF)
Last modified date: 3/21/2023 3:24 PM
