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Mental Health Services Division - DHCS - CA

Mental Health Services Division - DHCS - CA 2026

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The document is a confidential client information form from the Los Angeles County Department of Mental Health, designed to collect personal, financial, and insurance details of clients seeking mental health services. It includes sections for client demographics, payer financial information, income sources, asset valuations, and verification of benefits eligibility.

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Click ‘Get Form’ to open the Mental Health Services Division - DHCS - CA document in the editor.
Begin by filling out the 'Client Information' section. Enter your name, Social Security number, maiden name, DMH client ID, date of birth, and marital status. Ensure all details are accurate for proper processing.
Next, address the 'Payer Financial Information' section. Indicate if you have any financial support such as Medi-Cal or SSI by checking the appropriate boxes.
Proceed to the 'Third Party Information' area. Fill in details regarding any additional insurance coverage you may have, including Medicare and other relevant policies.
Complete the 'Payer References' section by providing information about your payer's relationship to you and their contact details.
Finally, review all entries for accuracy before signing at the bottom of the form. Use our platform’s tools to ensure everything is clear and legible.

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Versions	Form popularity	Fillable & printable
2023	4.3 Satisfied (44 Votes)
2011	4.9 Satisfied (49 Votes)
2004	4 Satisfied (23 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Does Medi-Cal have mental health services?

You can get mental health services through Medi-Cal. You can get them through fee-for-service or managed care plans. In addition, you can get Medi-Cal mental health services through county mental health plans.

How do I contact the California Department of health?

California Department of Public Health 916-928-8806 (phone) 1-888-942-9675 (WIC WORKS) (toll-free) 1-800-852-5770 (voc) 916-928-8341 (fax)

Is DHCS the same as Medi-Cal?

DHCS is the single state agency responsible for financing and administering the states Medicaid program, Medi-Cal, which provides health care services to low-income persons and families who meet defined eligibility requirements. Medi-Cal is authorized and funded through a federal-state partnership.

What number is 1 800 430 4263?

Health Care Options at 1-800-430-4263, Monday through Friday, 8:00 a.m. - 5:00 p.m. What is Medi-Cal Managed Care? Medi-Cal is Californias Medicaid program. It provides medical, dental, mental health, alcohol and drug use treatment, and vision care to millions of Californians.

How do I contact CA Dhcs?

Medi-Cal Contacts GENERAL PUBLICPHONE / EMAIL Other Health Coverage (OHC) (800) 541-5555 (916) 636-1980) Estate Recovery P.O. Box 997425, MS 4720 Sacramento, CA 95899-7425 (916) 650-0490 Medi-Cal Eligibility P.O. Box 997417, MS 4607 Sacramento, CA 95899-7417 (916) 552-920012 more rows Nov 7, 2024

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How do I contact DHCS Medi-Cal customer service?

Telephone Service Center 1-800-541-5555 The Telephone Service Center (TSC) is available from 8 a.m. to 5 p.m., Monday through Friday, except holidays.

What is the 3 month rule in mental health?

The Mental Health Licensing (MHL) Branch of the Department of Health Care Services (DHCS) is responsible for the licensing and oversight of mental health programs on a statewide basis, ranging from acute to long-term programs.

Mental Health Services Division - DHCS - CA 2026

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