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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

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California Area Office logoCalifornia Area Office

Forms and Applications

Please fill out and sign the application, patient registration and the agreement forms.  All documents must be submitted through secure messaging or fax. PLEASE DO NOT EMAIL.

Desert Sage Youth Wellness Center
P.O. Box 2748, Hemet, CA  92546
Office: (951) 708-4019
Secure Fax: (951) 767-1203 / (951) 767-3047

Additional intake assistance is available by contacting the Intake/Aftercare Coordinators Sabrina Lepkofker at (951) 708-4042 or via email or Teresa Phinazee at (951) 708-4043 or via email at

August 22, 2017
Letter from State of CA - DHCS - YRTC Referral Process for Medi-Cal Members (PDF)

Referral process for eligibility, referral, and payment processes for YRTC services provided to American Indians who are Medi-Cal members

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By State of California
May 15, 2017
Policy Memo - Billing, Reimbursements, Payments, Referrals & Travel (PDF)

Read this memo first.

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June 13, 2017
Admission Application (PDF)

Desert Sage Youth Wellness Center Admission Application

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June 13, 2017
Patient Registration Form (PDF)

This form is for the PARENT or GUARDIAN to fill out.

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June 13, 2017
Admission Agreement (PDF)

Regarding Medical/Dental Care Not Available at Riverside San Bernardino County Indian Health, Inc
Referring IHS/Tribal Program is responsible for Purchase/Referred Care

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