Outline
The California Department of Health Care Services (DHCS) requires every applicant or provider to complete the Medi-Cal Disclosure Statement (DHCS 6207) as part of the enrollment process for Medi-Cal providers. This form is crucial for both new applicants and those currently enrolled, as it ensures that all necessary information is disclosed accurately and completely. Failure to do so can lead to serious consequences, including denial of enrollment or deactivation of business addresses, along with a three-year reapplication bar. The form consists of several sections, including applicant/provider information, ownership interest details, and specific requirements for various types of providers, such as pharmacies and subcontractors. Clear instructions guide applicants on how to fill out the form correctly, emphasizing the importance of avoiding errors and omissions. Notably, the form must be submitted without staples and requires original signatures, ensuring that all submissions are legally binding. Understanding the requirements and implications of the DHCS 6207 form is essential for anyone looking to participate in the Medi-Cal program.
Sample - California Dhcs Form
State of California—Health and Human Services Agency Department of Health Care Services
Overall Authority: Code of Federal Regulations, Title 42, Part 455; California Code of Regulations, Title 22, Sections 51000–51451; Welfare and Institutions
Code, Sections 14043–14043.75
DHCS 6207 (Rev. 7/14)
Every applicant or provider must complete and submit a current Medi-Cal Disclosure Statement (DHCS 6207) as
part of a complete application package for enrollment, continued enrollment, or certification as a Medi-Cal provider.
Important:
• FOR NEW APPLICANTS: Failure to disclose complete and accurate information may result in a denial of
enrollment and imposition of a three-year reapplication bar.
• FOR CURRENTLY ENROLLED APPLICANTS: Failure to disclose complete and accurate information may
result in denial, deactivation of all business addresses and the imposition of a three-year reapplication bar.
The Department is required to report the termination of your participation in the Medi-Cal Program to the Centers
for Medicare and Medicaid Services and to other States’ Medicaid and Children’s Health Insurance Programs
pursuant to United States Code, Title 42, Sections 1396a(kk)(6) and 1902(kk)(6) and the Code of Federal
Regulations, Title 42, Section 1002.3(b).
• Submitting a complete and accurate Medi-Cal Disclosure Statement is required.
• Read all instructions when completing the Medi-Cal Disclosure Statement.
• Type or print clearly in ink.
• DO NOT USE staples on this form or on any attachments.
• If applicant/provider must make corrections, please line through, date, and initial in ink. Do not use correction
fluid.
• Return this completed statement with the complete application package to the address listed on the application
form.
DHCS 6207 (Rev. 7/14) i
TABLE OF CONTENTS
GENERAL INSTRUCTIONS ............................................................................................................................ ii
I. APPLICANT/PROVIDER INFORMATION ......................................................................................... 1
II. UNINCORPORATED SOLE-PROPRIETOR OR INDIVIDUAL RENDERING PROVIDER
ADDING TO A GROUP ..................................................................................................................... 4
III. OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ENTITIES) ................ 5
IV. OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) .......... 7
V. SUBCONTRACTOR ........................................................................................................................... 10
VI. INCONTINENCE SUPPLIES .............................................................................................................. 13
VII. PHARMACY APPLICANTS OR PROVIDERS ................................................................................... 14
VIII. DECLARATION AND SIGNATURE PAGE ....................................................................................... 15
DHCS 6207 (Rev. 7/14) ii
GENERAL INSTRUCTIONS FOR COMPLETING
THE MEDI-CAL DISCLOSURE STATEMENT
• DO NOT USE staples on this form or on any attachments.
• Do not use a pencil, correction tape, correction fluid, highlighter pen, etc. on this form.
• If you must correct an entry, the applicant or provider must initial and date the correction in ink.
• Do not leave any questions, boxes, lines, etc., blank. Check or write “N/A” if not applicable to you.
• To review the Title 22 provider enrollment regulations, please visit the Medi-Cal Website (www.medi-cal.ca.gov) and click the
“Provider Enrollment” link. It is the responsibility of the applicant/provider to comply with all regulations pertaining to Medi-
Cal.
Section I: Applicant/Provider Information
1. All applicants and providers must complete this Section unless they are eligible to use the “Medi-Cal Rendering Provider
Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers” (DHCS 6216) or the “Medi-Cal
Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement for Physician and Non-Physician
Practitioners” (DHCS 6219).
2. Rendering providers joining a group who are not eligible to use the “Medi-Cal Rendering Provider Application/Disclosure
Statement/Agreement for Physician/Allied/Dental Providers” may leave parts E–H blank if part D is checked.
3. If applicant leases the location where services are being rendered or provided, please attach a copy of a current signed
lease agreement.
4. In California, a domestic or foreign limited liability company is not permitted to render professional services, as defined in
Corporations Code Sections 13401, subdivision (a) and 13401.3. See
California Corporations Code Section 17375.
Section II: Unincorporated Sole-Proprietor or Individual Rendering Provider Adding to a Group
Disclosure of social security number is mandatory. (See Privacy Statement at bottom of page 15)
Section III: Ownership Interest and/or Managing Control Information (Entities)
1. To determine percentage of ownership, mortgage, deed of trust, note or other obligation, the percentage of interest owned
in the obligation is multiplied by the percentage of the disclosing entity’s assets used to secure the obligation. For example,
if A owns 10 percent of a note secured by 60 percent of the applicant’s or provider’s assets, A’s interest in the provider’s
assets equates to 6 percent and shall be reported pursuant to California Code of Regulations, Title 22, Section 51000.35.
Conversely, if B owns 40 percent of a note secured by 10 percent of the applicant’s or provider’s assets, B’s interest in the
provider’s assets equates to 4 percent and need not be reported.
2. “Indirect ownership interest” means an ownership interest in any entity that has an ownership interest in the applicant or
provider. This term includes an ownership interest in any entity that has an indirect ownership interest in the applicant or
provider. The amount of indirect ownership interest is determined by multiplying the percentages of ownership in each
entity. For example, if A owns 10 percent of the stock in a corporation which owns 80 percent of the stock of the applicant
or provider, A’s interest equates to an 8 percent indirect ownership interest in the applicant or provider and s hall be
reported pursuant to California Code of Regulations, Title 22, Section 51000.35. Conversely, if B owns 80 percent of the
stock of a corporation, which owns 5 percent of the stock of the applicant or provider, B’s interest equates to a 4 percent
indirect ownership interest in the applicant or provider and need not be reported.
3. “Ownership interest” means the possession of equity in the capital, the stock, or the profits of the applicant or provider.
4. All entities with managing control of applicant/provider must be listed in this Section.
5. List the National Provider Identifier (NPI) of each listed corporation, unincorporated association, partnership, or similar entity
having 5% or more (direct or indirect) ownership or control interest, or any partnership interest, in the applicant/provider
identified in Section I.
6. Corporations with ownership or control interest in the applicant or provider must provide all corporate business addresses
and the corporation Taxpayer Identification Number issued by the IRS. For verification, a legible copy of the IRS Form 941,
Form 8109-C, Letter 147-C, or Form SS-4 (Confirmation Notification) must be included.
Section IV: Ownership Interest and/or Managing Control Information (Individuals)
1. Refer to Section III instructions and definitions.
2. “Person with an ownership or control interest” means a person that:
a. Has an ownership interest of 5 percent or more in an applicant or provider;
b. Has an indirect ownership interest equal to 5 percent;
DHCS 6207 (Rev. 7/14) iii
c. Has a combination of direct and indirect ownership interest equal to 5 percent or more in an applicant or provider;
d. Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the applicant
or provider if that interest equals at least 5 percent of the value of the property or assets of the applicant or provider;
e. Is an officer or director of an applicant or provider that is organized as a corporation;
f. Is a partner in an applicant or provider that is organized as a partnership.
3. “Agent” means a person who has been delegated the authority to obligate or act on behalf of an applicant or provider.
4. “Managing employee” means a general manager, business manager, administrator, director, or other individual who
exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an
applicant or provider. All managing employees must be included in this section.
5. List the National Provider Identifier (NPI) of each individual with ownership or control interest or any partnership interest, in
the applicant/provider identified in Section I. I n addition, all officers of the corporation, directors, agents and managing
employees of the applicant/provider must be reported in this section.
6. Disclosure of social security number is mandatory. (See Privacy Statement at bottom of page 15)
Section V: Subcontractor and Significant Business Transactions
1. “Subcontractor” means an individual, agency, or organization:
a. To which an applicant or provider has contracted or delegated some of its management functions or responsibilities of
providing healthcare services, equipment, or supplies to its patients.
b. With whom an applicant or provider has entered into a contract, agreement, purchase order, lease, or leases of real
property, to obtain space, supplies, equipment, or services provided under the Medi-Cal Program.
2. “Significant business transaction” means any business transaction or series of transactions that involve health care
services, goods, supplies, or merchandise related to the provision of services to Medi-Cal beneficiaries that, during any one
fiscal year, exceed the lesser of $25,000 or 5 percent of an applicant’s or provider’s total operating expenses.
Section VI: Incontinence Supplies
1. Applicant or provider must check “Yes” or “No.”
2. If “Yes,” complete A–C.
Section VII: Pharmacy Applicants or Providers
All pharmacy applicants or providers must complete this Section.
Section VIII: Declaration and Signature Page
1. All applicants or providers must complete this Section.
2. Legal name of applicant/provider must match name listed on associated application package.
3. The signature must be an individual who is the sole proprietor, partner, corporate officer, or an official representative of a
governmental entity or nonprofit organization who has the authority to legally bind the applicant or provider. See Title 22,
CCR Section 51000.30(a)(2)(B).
4. An original signature is required. Stamped, faxed, and/or photocopied signatures are not acceptable.
5. Disclosure Statement must be notarized by a Notary Public except for those applicants and providers licensed pursuant to
Business and Professions Code, Division 2, beginning with Section 500. For example: Physicians, Pharmacy providers,
Chiropractors, Osteopaths, Certified Nurse Midwives, Nurse Practitioners and Dentists do not need to notarize this form.
Durable Medical Equipment (DME) providers, Prosthetics, Orthotics, Medical Transportation providers, etc., must notarize
this form.
FOR MORE INFORMATION, PLEASE VISIT THE MEDI-CAL WEBSITE (WWW.MEDI-CAL.CA.GOV)
AND CLICK THE “PROVIDER ENROLLMENT” LINK.
State of California—Health and Human Services Agency Department of Health Care Services
Do not leave any questions, boxes, lines, etc., blank.
DHCS 6207 (rev. 7/14) Page 1 of 15
MEDI-CAL DISCLOSURE STATEMENT
Do not leave any questions, boxes, lines, etc., blank. Check or enter N/A if not applicable to you.
I.
APPLICANT/PROVIDER I
NFORMATION
A.
Legal name of applicant/provider as reported to the IRS
B.
Legal name of applicant/provider as it appears on professional license IF NOT APPLICABLE, CHECK THE BOX N/A
C.
Existing provider numbers (NPI or Denti-Cal provider number as applicable) used at the address indicated in Item G below. N/A
D.
If applying as a rendering provider to a provider group, check here and proceed to Part I. (marked with *asterisk below)
E.
Fictitious business name N/A
F.
“Doing Business As” name N/A
G.
Address where services are rendered or provided (number, street)
(City)
(State)
(Nine-digit ZIP code)
1.
Does applicant/provider lease this location?
Yes No
2.
If YES, complete the following information regarding the Lessor and enclose a copy of the current signed Lease
Agreement
, including
any sublease agreements entered into by the applicant provider at the business address on the
A
pplication.
a.
Lessor name
b.
Lessor address (number, street)
(City)
(State)
(Nine-digit ZIP code)
c.
Lessor telephone number
d.
Term of lease
e.
Amount of lease
3.
If no, does applicant/provider own this location?
Yes No
4.
If applicant/provider does not lease or own this location, explain below:
H.
Type of Entity
(must check one):
General Partnership
(Enclose Partnership Agreement)
Limited Partnership
(Enclose Partnership Agreement)
Limited Liability Partnership
(Enclose Partnership Agreement)
Sole Proprietor (Unincorporated)
Limited Liability Company:
Governmental
State of formation:
Corporation
(Enclose Articles of Incorporation and
Statement of Information)
Corporate number:
State incorporated:
_____________________
Nonprofit:
Check one:
Check one:
Corporation
Charitable
Other (specify):
Unincorporated Association
Religious
*I.
List below fines/debts due and owing by applicant/provider to any federal, state, or local government that relate to Medicare,
Medicaid and
all
other federal and state health care programs that have not been paid and what arrangements have been made
to fulfill the obligation(s).
Submit copies of all documents
pertaining to the arrangements including terms and conditions. See
California Code of
Regulations (CCR), Title 22, Section 51000.50(a)(6).
N/A
FINE/DEBT
AGENCY
DATE ISSUED
DATE TO BE
PAID IN FULL
$
$
Do not leave any questions, boxes, lines, etc., blank.
DHCS 6207 (rev. 7/14) Page 2 of 15
I.
APPLICANT/PROVIDER INFORMATION (Continued)
J.
List the name and DGdress of all health care providers, participating or not participating in Medi-Cal, in which the
applicant/provider, listed in Part A, also has an ownership or control interest. If none, check N/A. If additional space is needed,
attach additional page (label “Additional Section I, Part J”).
N/A
1.
Full legal name of health care provider
2.
Address (number, street)
(City)
(State)
(Nine-digit ZIP code)
K.
Respond to the following questions:
1.
Within ten years of the date of this statement
, have you, the applicant/provider, been convicted
of any felony or misdemeanor involving fraud or abuse in any government program?
Yes
No
If yes, provide the date of the conviction (mm/dd/yyyy):
2.
Within ten years of the date of this statement,
have you, the applicant/provider, been found liable
for fraud or abuse involving a government program in any civil proceeding?
Yes
No
If yes, provide the date of final judgment (mm/dd/yyyy):
3.
Within ten years of the date
of this statement, have you, the applicant/provider, entered into a
settlement in lieu of conviction for fraud or abuse involving a government program?
Yes
No
If yes, provide the date of the settlement (mm/dd/yyyy):
4.
Do you, the applicant/provider, currently participate or have you ever participated as a provider in
the Medi
-Cal program or in another state’s Medicaid program?
If yes, provide the following information:
Yes
No
STATE
NAME(S)
(LEGAL AND DBA)
NPI AND/OR
PROVIDER NUMBER(S)
5.
Have you, the applicant/provider,
ever been suspended from a M edicare, Medicaid, or Medi-Cal
program?
If yes, attach verification of reinstatement
and provide the following information:
Yes
No
CHECK
APPLICABLE
PROGRAM
NPI AND/OR
PROVIDER NUMBER(S)
EFFECTIVE DATE(S) OF
SUSPENSION
DATE(S) OF REINSTATEMENT(S),
AS APPLICABLE
Medi-Cal
Medicaid
Medicare
Medi-Cal
Medicaid
Medicare
6.
Has the individual license, certificate, or other approval to provide health care of the applicant/provider
ever been suspended or revoked?
If yes, include copies of licensing authority decision(s) for each decision and written confirmation from
them that your professional privileges have been restored and provide the following information:
Yes
No
WHERE ACTION(S) WAS
TAKEN ACTION(S) TAKEN
EFFECTIVE DATE(S) OF
LICENSING AUTHORITY’S ACTION(S)
Do not leave any questions, boxes, lines, etc., blank.
DHCS 6207 (rev. 7/14) Page 3 of 15
I.
APPLICANT/PROVIDER INFORMATION (Continued)
7.
Have you, the applicant/provider,
ever lost or surrendered your license, certificate, or other approval
to provide health care
while a disciplinary hearing was pending?
If yes, attach a copy of the written confirmation from the
licensing authority that your professional
privileges have been restored and provide the following information:
Yes
No
WHERE ACTION(S) WAS
TAKEN ACTION(S) TAKEN
EFFECTIVE DATE(S) OF
LICENSING AUTHORITY’S ACTION(S)
8.
Has the license, certificate, or other approval to provide health care of the applicant/provider
ever
been disciplined by any licensing authority?
If yes, include copies of licensing authority decision(s) including any terms and conditions for each
decision and provide the following information:
Yes
No
WHERE ACTION(S) WAS
TAKEN ACTION(S) TAKEN
EFFECTIVE DATE(S) OF
LICENSING AUTHORITY’S ACTION(S)
• If you, the applicant/provider, are an unincorporated sole-proprietor
or an individual rendering provider adding to a group, proceed to
Section II.
OR
• If you, the applicant/provider, are a partnership, corporation,
governmental entity, or nonprofit organization, proceed to Section III.
Do not leave any questions, boxes, lines, etc., blank.
DHCS 6207 (rev. 7/14) Page 4 of 15
II.
UNINCORPORATED SOLE-PROPRIETOR OR INDIVIDUAL RENDERING PROVIDER ADDING TO A
GROUP
A.
Full legal name (Last) (Jr., Sr., etc.) (First) (Middle)
B.
Residence address (number, street)
(City)
(State)
(Nine-digit ZIP code)
C.
Social security number (required)
D.
Date of birth
E.
Driver’s license number or state-issued identification number (Attach a current and legible copy.)
• If you, the applicant/provider, are an unincorporated sole-proprietor,
proceed to Section V.
OR
• If you, the applicant/provider, are a rendering provider adding to a
group, proceed to Section VIII.
Do not leave any questions, boxes, lines, etc., blank.
DHCS 6207 (rev. 7/14) Page 5 of 15
III.
OWNERSHIP INTEREST A
ND/OR MANAGING CONTROL INFORMATION (ENTITIES)
A.
In the table below, list all corporations, unincorporated associations, partnerships, or similar entities having 5% or more (direct or
indirect) ownership or control
interest, or any partnership interest, in the applicant/provider identified in Section I.
Attach a
separate Section III, Part B and C for each entity listed below.
Number of pages attached: ______
Check here if this section does not apply and proceed to Section IV.
ENTITY LEGAL BUSINESS NAME
PERCENT (%) OF
OWNERSHIP OR
CONTROL
NPI NUMBER
(IF APPLICABLE)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Do not leave any questions, boxes, lines, etc., blank.
DHCS 6207 (rev. 7/14) Page 6 of 15
III.
OWNERSHIP INTEREST A
ND/OR MANAGING CONTROL INFORMATION (ENTITIES) (Continued)
B.
Entity with (Direct or Indirect) Ownership Interest and/or Managing Control
—Identification Information.
1.
Legal business name
2.
Doing Business As (DBA) name (if applicable) N/A
3.
Primary Business Address (number, street) *
(City)
(State)
(Nine-digit ZIP code)
* If this entity is a corporation, attach a list of ALL business location addresses and P. O. Box addresses of the corporation.
4.
If this entity is a corporation, list the Taxpayer Identification Number issued by the IRS and attach a legible copy of the IRS form.
5.
Check all that apply:
5% or more ownership interest
Managing control
Partner
Other (specify):
6.
Effective date of ownership (mm/dd/yyyy)
7.
Effective date of control (mm/dd/yyyy)
C.
Respond to the following questions:
1.
Within ten years from the date of this statement, has this entity been convicted of any felony or
misdemeanor involving fraud or abuse in any government program?
Yes
No
If yes, provide the date of the conviction (mm/dd/yyyy):
2.
Within ten years from the date of this statement,
has this entity been found liable for fraud or
abuse involving any government program in any civil proceeding?
Yes
No
If yes, provide the date of final judgment (mm/dd/yyyy):
3.
Within ten years from the date of this statement,
has this entity entered into a settlement in lieu of
conviction for fraud or abuse involving any government program?
Yes
No
If yes, provide the date of the settlement (mm/dd/yyyy):
4.
Does this entity currently participate, or has this entity ever participated, as a provider in the Medi
-Cal
program or in another state’s Medicaid
program? If yes, provide the following information:
Yes
No
STATE
NAME(S)
(LEGAL AND DBA)
NPI AND/OR
PROVIDER NUMBER(S)
5.
Has this entity ever been suspended from a Medicare, Medicaid, or Medi
-Cal program?
If yes, attach verification of reinstatement and provide the following information:
Yes
No
CHECK
APPLICABLE
PROGRAM
NPI AND/OR
PROVIDER NUMBER(S)
EFFECTIVE DATE(S) OF
SUSPENSION
DATE(S) OF REINSTATEMENT(S),
AS APPLICABLE
Medi-Cal
Medicaid
Medicare
Medi-Cal
Medicaid
Medicare
6.
List the name and address of all health care providers, participating or not participating in Medi
-
Cal, in which this entity also
has an ownership or control interest.
If none, check here.
If additional space is needed, attach additional page (label “Additional Section III, Part C, Item 6”).
Number of pages attached:____
a.
Full legal name of health care provider (include any fictitious business names)
b.
Address (number, street)
(City)
(State)
(Nine-digit ZIP code)
Form Information
| Fact Name | Fact Details |
|---|---|
| Form Title | Medi-Cal Disclosure Statement (DHCS 6207) |
| Governing Law | United States Code, Title 42, Sections 1396a(kk)(6) and 1902(kk)(6) |
| Required Submission | All applicants or providers must submit a current DHCS 6207 for enrollment or continued enrollment. |
| New Applicants | Failure to provide accurate information may lead to denial of enrollment and a three-year reapplication bar. |
| Current Applicants | Inaccurate disclosures can result in denial, deactivation of business addresses, and a three-year reapplication bar. |
| Submission Guidelines | Complete and accurate information is mandatory; do not use staples or correction fluid. |
| Authority References | Code of Federal Regulations, Title 42, Part 455; California Code of Regulations, Title 22, Sections 51000–51451. |
| Signature Requirement | An original signature is required, and notarization is mandatory for certain providers. |
Detailed Guide for Filling Out California Dhcs
Completing the California DHCS form is an essential step for applicants and providers seeking enrollment or continued participation in the Medi-Cal program. Ensure that all information is accurate and complete, as any discrepancies can lead to significant delays or denials. Follow the steps below to fill out the form correctly.
- Begin by reading all instructions carefully to understand the requirements.
- Type or print clearly in ink. Avoid using pencils or correction fluid.
- In Section I, provide your legal name as reported to the IRS and as it appears on your professional license, if applicable.
- List any existing provider numbers you have, such as your NPI or Denti-Cal number.
- If you are applying as a rendering provider to a group, check the appropriate box.
- Fill in the fictitious business name and “Doing Business As” name, if applicable.
- Complete the address section with the location where services are rendered, including city, state, and ZIP code.
- Indicate whether you lease or own the location where services are provided. If leasing, provide the lessor's details and attach a current signed lease agreement.
- Check the type of entity you are (e.g., General Partnership, Sole Proprietor, Nonprofit, etc.).
- In Section I, list any fines or debts owed to government agencies related to Medicare or Medicaid, if applicable, and submit supporting documents.
- Proceed through the remaining sections, providing the required information for ownership interests, managing control, subcontractors, and any specific sections relevant to your application.
- In Section VIII, sign and date the form. Ensure the signature is from an authorized individual.
- If required, have the form notarized, except for certain licensed professionals.
- Submit the completed form with your application package to the address specified on the application form.
Obtain Answers on California Dhcs
-
What is the purpose of the California DHCS form?
The California DHCS form, specifically the Medi-Cal Disclosure Statement (DHCS 6207), is a required document for all applicants and providers seeking enrollment, continued enrollment, or certification as Medi-Cal providers. It ensures that all necessary and accurate information is disclosed, which is crucial for compliance with federal and state regulations.
-
Who needs to complete the DHCS form?
Every applicant or provider must complete the DHCS form unless they qualify to use alternative forms, such as the “Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers” (DHCS 6216) or the “Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement” (DHCS 6219).
-
What happens if I fail to provide complete and accurate information?
Failure to disclose complete and accurate information can lead to serious consequences. New applicants may face denial of enrollment and a three-year reapplication bar. Currently enrolled providers may experience denial, deactivation of business addresses, and the same three-year reapplication bar.
-
How should I fill out the DHCS form?
When completing the DHCS form, it is essential to:
- Type or print clearly in ink.
- Avoid leaving any questions or boxes blank; use "N/A" where applicable.
- Make corrections by crossing out the incorrect information, dating, and initialing it in ink. Do not use correction fluid or staples.
-
Is there a specific format for submitting the form?
Yes, the completed DHCS form must be submitted along with the entire application package to the address specified on the application form. Ensure that all required documents are included to avoid delays.
-
What information is required regarding ownership and control?
The form requires detailed information about ownership interest and managing control. This includes identifying individuals or entities with a 5% or more ownership interest, as well as any indirect ownership interests. Accurate reporting is crucial to comply with state regulations.
-
Do I need to provide my Social Security number?
Yes, disclosure of your Social Security number is mandatory for certain sections of the form. This information is used for verification and compliance purposes.
-
Are there any notarization requirements?
Most applicants and providers must have their DHCS form notarized. However, certain licensed professionals, such as physicians and pharmacists, are exempt from this requirement. Always check the specific guidelines applicable to your profession.
-
What if I am a subcontractor?
If you are a subcontractor, you must disclose your relationship with the primary applicant or provider. This includes any contracts or agreements that involve healthcare services or supplies related to Medi-Cal beneficiaries.
-
Where can I find additional information about the DHCS form?
For more information, you can visit the Medi-Cal website at www.medi-cal.ca.gov. Click on the “Provider Enrollment” link to access resources and guidelines related to the DHCS form and the enrollment process.
Common mistakes
Filling out the California DHCS form can be a daunting task. Many applicants make mistakes that can lead to delays or even denials in their applications. One common mistake is leaving questions unanswered. Every question must be addressed, even if that means marking it as "N/A" if it does not apply. Leaving any section blank can raise red flags and complicate the review process.
Another frequent error is not providing accurate information. It is crucial to ensure that all details, such as the legal name of the applicant or provider, match what is reported to the IRS. Discrepancies can lead to confusion and potential rejection of the application.
Some applicants overlook the requirement to sign and date the form. An original signature is necessary; stamped or photocopied signatures are not acceptable. This oversight can result in the application being deemed incomplete.
Incorrectly handling corrections is another mistake. If changes are needed, applicants should line through the incorrect information, initial, and date the correction in ink. Using correction fluid or tape is not permitted and could invalidate the application.
Failure to include required attachments is also a common issue. If the applicant leases the location where services are provided, a signed lease agreement must be included. Missing documents can stall the application process.
Some individuals do not check the box for their type of entity. This step is essential, as it helps categorize the applicant correctly. Not doing so can lead to misclassification and delays in processing.
Providing incomplete ownership interest information can create problems as well. All individuals with a 5% or more ownership interest must be disclosed. Omitting this information could result in compliance issues down the line.
Another mistake is neglecting to notarize the form when required. While certain providers are exempt from notarization, many must have their disclosure statement notarized. Failing to do so could lead to rejection.
Some applicants may also forget to include their National Provider Identifier (NPI) numbers. These identifiers are crucial for processing and must be provided for all listed entities and individuals with ownership or control interest.
Lastly, not reading the instructions thoroughly can lead to various mistakes. Each section has specific requirements, and understanding these is vital for a successful application. Taking the time to carefully review the guidelines can save applicants from unnecessary complications.
Documents used along the form
The California Department of Health Care Services (DHCS) form is a crucial document for those seeking to enroll or maintain their status as Medi-Cal providers. However, this form is often accompanied by several other documents that help to provide a comprehensive view of the applicant's qualifications and business operations. Below is a list of common forms and documents that may be used alongside the DHCS form.
- Medi-Cal Rendering Provider Application (DHCS 6216): This application is specifically for individual rendering providers who are applying to join a provider group. It streamlines the process for those who meet certain eligibility criteria.
- Medi-Cal Ordering/Referring/Prescribing Provider Application (DHCS 6219): This form is designed for healthcare professionals who need to order, refer, or prescribe services for Medi-Cal beneficiaries. It ensures that these providers meet the necessary requirements.
- Lease Agreement: If the applicant leases their business location, a current signed lease agreement must be submitted. This document confirms the applicant's right to operate at the specified address.
- IRS Form 941: This form is used to report payroll taxes and is often required to verify the tax status of corporations or entities involved in the application process.
- Articles of Incorporation: For applicants that are corporations, this document outlines the company's formation and structure. It is essential for verifying ownership and control interests.
- Partnership Agreement: If the applicant is part of a partnership, this agreement details the terms of the partnership and must be submitted to clarify ownership interests.
- National Provider Identifier (NPI) Registration: This document provides the NPI number assigned to healthcare providers. It is essential for billing and identification purposes within the Medi-Cal system.
- Notarized Declaration: Certain applicants, particularly those in specific healthcare fields, must provide a notarized declaration confirming the accuracy of the information submitted in the application. This adds an extra layer of verification.
Each of these documents plays a vital role in the application process for Medi-Cal providers in California. They collectively ensure that the information provided is accurate, complete, and compliant with state and federal regulations. Understanding these requirements can facilitate a smoother enrollment process and help maintain compliance with Medi-Cal standards.
Similar forms
The California DHCS form, specifically the Medi-Cal Disclosure Statement (DHCS 6207), shares similarities with several other important documents used in the healthcare industry. Here are four documents that are comparable to the DHCS 6207:
- Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement (DHCS 6216): This document is used by rendering providers who are applying to join a provider group. Like the DHCS 6207, it requires detailed information about ownership and control interests, ensuring transparency in the enrollment process.
- Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement (DHCS 6219): This form is for providers who order, refer, or prescribe services for Medi-Cal beneficiaries. Similar to the DHCS 6207, it mandates disclosure of ownership and control interests to maintain compliance with regulatory standards.
- Provider Enrollment Application (CMS-855): Used by healthcare providers to enroll in Medicare, this application requires similar disclosures regarding ownership and control. Both forms aim to prevent fraud and ensure that only qualified providers participate in government healthcare programs.
- National Provider Identifier (NPI) Application (CMS-10114): This application is necessary for healthcare providers to obtain a unique identifier. Like the DHCS 6207, it requires detailed information about the provider's business structure and ownership, promoting accountability within the healthcare system.
Dos and Don'ts
When filling out the California DHCS form, here are five important do's and don'ts to keep in mind:
- Do read all instructions carefully before you start filling out the form.
- Do provide complete and accurate information to avoid denial of enrollment.
- Do type or print clearly in ink to ensure legibility.
- Don't leave any questions or boxes blank; use "N/A" if not applicable.
- Don't use staples or correction fluid; make corrections by lining through, dating, and initialing in ink.
Following these guidelines will help ensure a smoother application process.
Misconceptions
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Misconception 1: The DHCS form is optional for applicants.
This is incorrect. Every applicant or provider must complete and submit the Medi-Cal Disclosure Statement (DHCS 6207) as part of their application package. Failing to do so may lead to denial of enrollment.
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Misconception 2: Corrections can be made using correction fluid or tape.
This is not allowed. If corrections are necessary, applicants must line through the error, date it, and initial in ink. Using correction fluid or tape is prohibited.
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Misconception 3: Only new applicants need to worry about accurate disclosures.
This is misleading. Current providers must also provide complete and accurate information. Inaccuracies can lead to deactivation of business addresses and a three-year reapplication bar.
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Misconception 4: The form does not need to be notarized.
This is not true for all applicants. While certain licensed professionals are exempt from notarization, many providers, such as Durable Medical Equipment providers, must have the form notarized.
Key takeaways
Filling out and using the California DHCS form, specifically the Medi-Cal Disclosure Statement (DHCS 6207), is a critical process for applicants and providers. Here are key takeaways to keep in mind:
- Complete and Accurate Information: Every applicant or provider must provide complete and accurate information. Inaccuracies can lead to denial of enrollment and a three-year reapplication bar.
- Mandatory Submission: The Medi-Cal Disclosure Statement is a required component of the application package for enrollment or continued enrollment as a Medi-Cal provider.
- Read Instructions Carefully: Applicants should read all instructions thoroughly before completing the form to avoid mistakes that could jeopardize their application.
- Clear Writing: Use clear, legible handwriting or type the information. Avoid using staples on the form or any attachments.
- Corrections: If corrections are necessary, applicants must line through the incorrect information, date, and initial the changes in ink. Avoid using correction fluid or tape.
- Return Address: The completed form must be returned with the full application package to the address specified on the application form.
- Ownership Disclosure: All ownership interests and managing control information must be disclosed, including percentages and relevant identifiers.
- Signatures Required: The form must be signed by an individual authorized to bind the applicant or provider legally. Stamped or photocopied signatures are not acceptable.
- Notarization: Certain applicants and providers are required to have the Disclosure Statement notarized, while others are exempt. Check the specific requirements for your category.
- Compliance with Regulations: Applicants are responsible for understanding and complying with all applicable regulations related to Medi-Cal enrollment.
Understanding these points can significantly streamline the process of filling out and submitting the California DHCS form, ultimately aiding in successful enrollment as a Medi-Cal provider.