California Department of Managed Health Care Forms
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Form DMHC20-160 "Authorized Assistant Form" - California
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Formulario DMHC20-160 "Formulario De Asistente Autorizado" - California (Spanish)
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Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California
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135 votes
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5 pages
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Formulario DMHC20-224 "Formulario De Queja/Solicitud De Revision Medica Independiente (Imr)" - California (Spanish)
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Form DMHC20-224 "Independent Medical Review Application (Imr)/Complaint Form" - California (Hmong)
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79 votes
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Form DMHC20-224 "Independent Medical Review Application (Imr)/Complaint Form" - California (Arabic)
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61 votes
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183 KB
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Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Hindi)
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68 votes
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123 KB
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Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Armenian)
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34 votes
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143 KB
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Form DMHC20-224 "Imr Application/Complaint Form" - California (Chinese)
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45 votes
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Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Farsi)
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Form DMHC20-224 "Independent Medical Review Application (Imr)/Complaint Form" - California (Tagalog)
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Form DMHC20-224 "Imr Application/Complaint Form" - California (Korean)
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Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Japanese)
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420 KB
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Form DMHC20-224 "Imr Application/Complaint Form" - California (Vietnamese)
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9 votes
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259 KB
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Form DMHC20-224 "Imr Application/Complaint Form" - California (Khmer)
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186 KB
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Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Thai)
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86 votes
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160 KB
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Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Punjabi)
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Formulario DMHC62-226 "Language Access Complaint Form" - California (Spanish)
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38 votes
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Form DMHC62-226 "Language Access Complaint Form" - California
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Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Lao)
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103 votes
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1 MB
6 pages
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"Cobra Continuation Services - Benefit Termination Form" - California
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25 votes
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59 KB
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"California Managed Care Members Grievance Form" - California
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8 votes
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27 KB
2 pages
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![Form DMHC20-160 "Authorized Assistant Form" - California](https://data.templateroller.com/pdf_docs_html/2063/20630/2063000/form-dmhc20-160-authorized-assistant-form-california.png "Form DMHC20-160 "Authorized Assistant Form" - California")
![Formulario DMHC20-160 "Formulario De Asistente Autorizado" - California (Spanish)](https://data.templateroller.com/pdf_docs_html/2063/20630/2063001/formulario-dmhc20-160-formulario-de-asistente-autorizado-california-spanish.png "Formulario DMHC20-160 "Formulario De Asistente Autorizado" - California (Spanish)")
![Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California](https://data.templateroller.com/pdf_docs_html/2063/20630/2063002/form-dmhc20-224-independent-medical-review-imr-application-complaint-form-california.png "Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California")
![Formulario DMHC20-224 "Formulario De Queja/Solicitud De Revision Medica Independiente (Imr)" - California (Spanish)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787904/form-dmhc-20-224-formulario-de-queja-solicitud-de-revision-medica-independiente-imr-california.png "Formulario DMHC20-224 "Formulario De Queja/Solicitud De Revision Medica Independiente (Imr)" - California (Spanish)")
![Form DMHC20-224 "Independent Medical Review Application (Imr)/Complaint Form" - California (Hmong)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787907/form-dmhc-20-224-independent-medical-review-application-imr-complaint-form-california.png "Form DMHC20-224 "Independent Medical Review Application (Imr)/Complaint Form" - California (Hmong)")
![Form DMHC20-224 "Independent Medical Review Application (Imr)/Complaint Form" - California (Arabic)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787908/form-dmhc-20-224-independent-medical-review-application-imr-complaint-form-california.png "Form DMHC20-224 "Independent Medical Review Application (Imr)/Complaint Form" - California (Arabic)")
![Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Hindi)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787909/form-dmhc-20-224-independent-medical-review-imr-application-complaint-form-california.png "Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Hindi)")
![Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Armenian)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787910/form-dmhc-20-224-independent-medical-review-imr-application-complaint-form-california.png "Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Armenian)")
![Form DMHC20-224 "Imr Application/Complaint Form" - California (Chinese)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787911/form-dmhc-20-224-imr-application-complaint-form-california.png "Form DMHC20-224 "Imr Application/Complaint Form" - California (Chinese)")
![Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Farsi)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787913/form-dmhc-20-224-independent-medical-review-imr-application-complaint-form-california.png "Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Farsi)")
![Form DMHC20-224 "Independent Medical Review Application (Imr)/Complaint Form" - California (Tagalog)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787914/form-dmhc-20-224-independent-medical-review-application-imr-complaint-form-california.png "Form DMHC20-224 "Independent Medical Review Application (Imr)/Complaint Form" - California (Tagalog)")
![Form DMHC20-224 "Imr Application/Complaint Form" - California (Korean)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787929/form-dmhc-20-224-imr-application-complaint-form-california.png "Form DMHC20-224 "Imr Application/Complaint Form" - California (Korean)")
![Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Japanese)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787930/form-dmhc-20-224-independent-medical-review-imr-application-complaint-form-california.png "Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Japanese)")
![Form DMHC20-224 "Imr Application/Complaint Form" - California (Vietnamese)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787938/form-dmhc-20-224-imr-application-complaint-form-california.png "Form DMHC20-224 "Imr Application/Complaint Form" - California (Vietnamese)")
![Form DMHC20-224 "Imr Application/Complaint Form" - California (Khmer)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787912/form-dmhc-20-224-imr-application-complaint-form-california.png "Form DMHC20-224 "Imr Application/Complaint Form" - California (Khmer)")
![Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Thai)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787919/form-dmhc-20-224-independent-medical-review-imr-application-complaint-form-california.png "Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Thai)")
![Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Punjabi)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787920/form-dmhc-20-224-independent-medical-review-imr-application-complaint-form-california.png "Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Punjabi)")
![Formulario DMHC62-226 "Language Access Complaint Form" - California (Spanish)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787917/form-dmhc-62-226-language-access-complaint-form-california.png "Formulario DMHC62-226 "Language Access Complaint Form" - California (Spanish)")
![Form DMHC62-226 "Language Access Complaint Form" - California](https://data.templateroller.com/pdf_docs_html/1789/17898/1789851/form-dmhc-62-226-language-access-complaint-form-california.png "Form DMHC62-226 "Language Access Complaint Form" - California")
![Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Lao)](https://data.templateroller.com/pdf_docs_html/1787/17879/1787922/form-dmhc-20-224-independent-medical-review-imr-application-complaint-form-california.png "Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California (Lao)")
!["Cobra Continuation Services - Benefit Termination Form" - California](https://data.templateroller.com/pdf_docs_html/8/84/8466/cobra-continuation-services-benefit-termination-form-california.png ""Cobra Continuation Services - Benefit Termination Form" - California")
!["California Managed Care Members Grievance Form" - California](https://data.templateroller.com/pdf_docs_html/7/73/7302/california-managed-care-members-grievance-form-california.png ""California Managed Care Members Grievance Form" - California")
