California Office of Statewide Health Planning & Development

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MIRCal - Forms

MIRCal User Registration Information and Forms

• MIRCal User Registration Information
  To access MIRCal, all facilities must first complete the following forms:
• User Account Administrator (UAA) Agreement and instructions
• Facility Contact Information
• Agent Designation Form (if applicable)
• Designated Agents Registration Information
  All potential Designated Agents (DA) must first complete the following form:
• Designated Agent User Agreement and instructions.

MIRCal Reporting Forms

• ED Encounters, #OSHPD 1370.ED
  For encounters through December 31, 2008
• ED Encounters, #OSHPD 1370.ED
  For encounters on or after January 1, 2009
• AS Encounters, #OSHPD 1370.AS
  For encounters through December 31, 2008
• AS Encounters, #OSHPD 1370.AS
  For encounters on or after January 1, 2009
• IP Discharge Data, #OSHPD 1370.IP
  For discharges on or after July 1, 2008
• IP Discharge Data, #OSHPD 1370.IP
  For discharges on or after January 1, 2009

Other Forms

• Appeal Documents
• Extension Request Form
• No Data to Report: Verification to OSHPD that your facility does not have data to report for the current open report period.
• Modification for Consolidation: Prior to submitting separate data reports, a consolidated facility must request a modification. (Refer to Reporting Manuals:  Reporting Requirements, section 97213 (g) and Requests, section 97240.)