DMC Sample Forms

Required Forms

(These Forms Are Not To Be Modified)

• Drug Medi-Cal Monthly Summary Invoice (ADP 1592) (PDF)  (MS Excel)  NEW!
• Drug Medi-Cal Resubmission Form (ADP 100201) (PDF)
• Drug Medi-Cal Reject Form (ADP 100202) (PDF)

Sample Forms

Sample forms are provided as a guide, but not a requirement, for DMC treatment providers. These forms contain the minimum information necessary to meet the requirements of the Title 22 regulations for various aspects of the treatment episode. You are free to use these samples, and add to them, if you would like additional information. However, make sure that you have read the regulations in their entirety and that you do not edit out crucial information from these forms.
Important: if the forms are not completely filled out or filled out incorrectly—recoupments may result.

• Physical Examination Waiver (PDF)
• Treatment Plan (PDF)
• Continuing Stay Justification (PDF)
• Second Service Same Day Progress Note (PDF)
• Progress Note (PDF)
• Discharge Summary (PDF)
• ADP 7700 (PDF)
• Good Cause Certification (XLS)
• Notification of a Action Page 1 (PDF)
• Notification of a Action Page 2 (PDF)