CDPH 8445 (PDF) - Comprehensive Health Care Coverage Form
CDPH 8445 SP (PDF) - Comprehensive Health Care Coverage Form (Spanish)
CDPH 8720 (PDF) - Agreement by Employee/Contractor to Comply with Confidentiality Requirements
CDPH 8723 (PDF) - Client Attestation
CDPH 8723 SP (PDF) - Client Attestation (Spanish
CDPH 8444 (PDF) ā Client Handout Form
CDPH 8730 (PDF) - Confidential Fax Submission
CDPH 8685 (PDF) - Consent Form
CDPH 8685 SP (PDF) - Consent Form (Spanish)
CDPH 8440 (PDF) āDiagnosis Form
CDPH 8729 (PDF) - Eligibility Exception Request (EER)
CDPH 8439 (PDF) - Enrollment Application
CDPH 8439 SP (PDF) - Enrollment Application (Spanish)
CDPH 8542 (PDF) - Grievance Form
CDPH 8542 SP (PDF) - Grievance Form (Spanish)
CDPH 8441 (PDF) - Income Verification Affidavit
CDPH 8441 SP (PDF) - Income Verification Affidavit (Spanish)
CDPH 8724 (PDF) - Medi-Cal Eligibility Exception Request (MEER)
CDPH 8731 (PDF) - New Enrollment Worker Training Request Form
CDPH 8442 (PDF) - Provider Verification of Identify
CDPH 8727 (PDF) - Residency Verification Affidavit
CDPH 8727 SP (PDF) - Residency Verification Affidavit (Spanish)
CDPH 8456 A (PDF) - Revocation of Special Power of Attorney
CDPH 8726 (PDF) - Self Employment Affidavit
CDPH 8726 SP (PDF) ā Self-Employment Affidavit (Spanish)
CDPH 8456 (PDF) - Special Power of Attorney
CDPH 8728 (PDF) - Temporary Access Period (TAP) Request
CDPH 8728 (PDF) - Temporary Access Period (TAP) Request (Spanish)
CDPH 9114 (PDF) - PrEP-AP Pharmacy User Training Request
CDPH 8738 (PDF) - Acknowledgement of Policies and Responsibilities Health Insurance Premium Payment (HIPP) Program Family Plan
CDPH 8732 (PDF) - Client Responsibilities Form
CDPH 8732 SP (PDF) - Client Responsibilities Form (Spanish)
CDPH 8737 (PDF) - Family Plan Consent Form
CDPH 8443 (PDF) - Medical Out-of-Pocket Claim Form
CDPH 8443 SP (PDF) - Medical Out-of-Pocket Claim Form (Spanish)
CDPH 8722 (PDF) - Partial Payment Agreement Form
CDPH 8722 (PDF) - Partial Payment Agreement Form (Spanish)