DHCS Authorization to Share Confidential Member Information (ASCMI) Form 2.0 Release
| Date: | March 11, 2026 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan All Providers |
| Type: | Informational/Educational |
| Subject: | DHCS Authorization to Share Confidential Member Information (ASCMI) Form 2.0 Release |
| Business: | Medi-Cal Managed Care |
The Department of Health Care Services (DHCS) has released the Authorization to Share Confidential Member Information (ASCMI) Form 2.0. The ASCMI Form is a standardized consent to share information form that providers may use to obtain an individual’s consent to share certain sensitive physical health, behavioral health, housing, and social services information.
To support care coordination across California, DHCS developed two versions of the ASCMI Form, AB 133 and Non-AB 133:
AB 133- https://www.dhcs.ca.gov/CalAIM/Documents/CALAIM/ASCMI-Form-AB-133-English.pdf
To authorize data sharing for the following individuals:
- Individuals enrolled in a Medi-Cal managed care plan.
- Individuals receiving behavioral health services under Medi-Cal.
- Individuals involved in the criminal legal system that qualify for pre-release Medi-Cal benefits.
Non-AB 133- https://www.dhcs.ca.gov/CalAIM/Documents/CALAIM/ASCMI-Form-Non-AB-133-English.pdf
To authorize data sharing for the following individuals:
- Not enrolled in a Medi-Cal managed care plan.
- Not receiving behavioral health services under Medi-Cal.
- Not involved in the criminal legal system that qualify for pre-release Medi-Cal benefits.
DHCS has also developed an ASCMI Revocation Form that may be used to withdraw consent if desired, found here: https://www.dhcs.ca.gov/CalAIM/Documents/CALAIM/ASCMI-Revocation-Form-English.pdf
More details about how to use the form, FAQs, and a recording of the webinar announcing the release can be found at https://www.dhcs.ca.gov/CalAIM/Pages/ASCMI-CalAIM.aspx
DHCS encourages providers to begin using the ASCMI Form when requesting clients’ consent to share sensitive information, as applicable.
DHCS is working with counties through an early adopter cohort to design and develop methods to electronically collect and transmit ASCMI Forms. Additional data-sharing resources for providers and stakeholder partners, including guidance on when consent may be required to share or receive information, can be found at DHCS’ Data Exchange and Sharing landing page found here: https://www.dhcs.ca.gov/dataandstats/Pages/DHCS-Data-Exchange-and-Data-Sharing.aspx.
Questions may be submitted to DHCSDataSharing@dhcs.ca.gov.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
