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California health care services 2026
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- Click ‘Get Form’ to open the California Health Care Services document in the editor.
- Begin by filling out Section I, which includes patient/client information. Enter the name, birth date, and Social Security or Medi-Cal number accurately.
- In the authorization section, specify the licensed physician or certified psychologist's name and their clinic. Ensure you understand that this authorization is valid for one year.
- Proceed to Section II to indicate if the individual has been diagnosed with a maternal mental health condition. Select 'Yes' or 'No' and provide the onset date if applicable.
- Finally, ensure that the treating health care provider signs and dates the form, providing their printed name, title/specialty, phone number, and mailing address.
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