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Blank California Dhcs PDF Form

The California DHCS form, officially known as the Medi-Cal Disclosure Statement (DHCS 6207), is a crucial document that applicants and providers must complete to enroll, maintain enrollment, or certify as Medi-Cal providers. This form requires detailed information about the applicant's or provider's ownership interests, managing control, and business operations, ensuring compliance with state and federal regulations. Accurate and complete disclosure is essential to avoid potential penalties, including denial of enrollment and a three-year reapplication bar. To get started on filling out the form, please click the button below.

Article Guide

The California Department of Health Care Services (DHCS) requires all applicants and providers to complete the Medi-Cal Disclosure Statement (DHCS 6207) as a crucial part of their application for enrollment, continued enrollment, or certification as a Medi-Cal provider. This form serves multiple purposes, ensuring that the information provided is complete and accurate, which is vital for maintaining the integrity of the Medi-Cal program. New applicants must be particularly cautious, as any omission or inaccuracy may lead to denial of enrollment and a three-year reapplication bar. Current providers face similar risks, including potential deactivation of their business addresses. The form includes sections that require detailed information about the applicant or provider, ownership interests, managing control, and any subcontractors involved in the provision of services. Specific guidelines dictate how to fill out the form, including the prohibition of staples and the requirement for corrections to be made in ink. Additionally, certain applicants must provide notarized signatures, while others are exempt. Understanding these requirements is essential for anyone looking to navigate the Medi-Cal system effectively.

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State of California—Health and Human Services Agency

Department of Health Care Services

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.

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)

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)

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).

Do not leave any questions, boxes, lines, etc., blank. Check or write “N/A” if not applicable to you.

If you must correct an entry, the applicant or provider must initial and date the correction in ink.

Do not use a pencil, correction tape, correction fluid, highlighter pen, etc. on this form.

DO NOT USE staples on this form or on any attachments.

•

• 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.

GENERAL INSTRUCTIONS FOR COMPLETING THE MEDI-CAL DISCLOSURE STATEMENT

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)

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. In 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.

DHCS 6207 (Rev. 7/14)

iii

State of California—Health and Human Services Agency

Department of Health Care Services

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 INFORMATION

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 Application.

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

4. If applicant/provider does not lease or own this location, explain below:

H.Type of Entity (must check one):

General Partnership	Limited Partnership			Limited Liability Partnership
(Enclose Partnership Agreement)	(Enclose Partnership Agreement)			(Enclose Partnership Agreement)
Sole Proprietor (Unincorporated)	Limited Liability Company:			Governmental
Corporation	State of formation:
Corporation			State incorporated:
(Enclose Articles of Incorporation and	Corporate number:		State incorporated:
Statement of Information)			_____________________
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 1 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?	Yes	No

If yes, provide the following information:

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?			Yes	No
	If yes, attach verification of reinstatement and provide the following information:

	CHECK
	APPLICABLE	NPI AND/OR	EFFECTIVE DATE(S) OF	DATE(S) OF REINSTATEMENT(S),
	APPLICABLE		EFFECTIVE DATE(S) OF	DATE(S) OF REINSTATEMENT(S),
	PROGRAM	PROVIDER NUMBER(S)	SUSPENSION	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?			Yes	No

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:

WHERE ACTION(S) WAS

TAKEN

ACTION(S) TAKEN

EFFECTIVE DATE(S) OF

LICENSING AUTHORITY’S ACTION(S)

DHCS 6207 (rev. 7/14)

Do not leave any questions, boxes, lines, etc., blank.

Page 2 of 15

I. APPLICANT/PROVIDER INFORMATION (Continued)

7.	Have you, the applicant/provider, ever lost or surrendered your license, certificate, or other approval	Yes	No
	to provide health care while a disciplinary hearing was pending?	Yes	No

	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:

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?	Yes	No

If yes, include copies of licensing authority decision(s) including any terms and conditions for each decision and provide the following information:

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.

•If you, the applicant/provider, are a partnership, corporation, governmental entity, or nonprofit organization, proceed to Section III.

DHCS 6207 (rev. 7/14)

Do not leave any questions, boxes, lines, etc., blank.

Page 3 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.

•If you, the applicant/provider, are a rendering provider adding to a group, proceed to Section VIII.

DHCS 6207 (rev. 7/14)

Do not leave any questions, boxes, lines, etc., blank.

Page 4 of 15

III.OWNERSHIP INTEREST AND/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	NPI NUMBER
OWNERSHIP OR
CONTROL	(IF APPLICABLE)

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

DHCS 6207 (rev. 7/14)

Do not leave any questions, boxes, lines, etc., blank.

Page 5 of 15

III.OWNERSHIP INTEREST AND/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	Yes	No
	program or in another state’s Medicaid program? If yes, provide the following information:

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?

Yes

If yes, attach verification of reinstatement and provide the following information:

CHECK	NPI AND/OR
APPLICABLE	NPI AND/OR	EFFECTIVE DATE(S) OF	DATE(S) OF REINSTATEMENT(S),
		EFFECTIVE DATE(S) OF	DATE(S) OF REINSTATEMENT(S),

PROGRAM	PROVIDER NUMBER(S)	SUSPENSION	AS APPLICABLE
PROGRAM

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)

DHCS 6207 (rev. 7/14)

Do not leave any questions, boxes, lines, etc., blank.

Page 6 of 15

➤ PDF File

Form Specifications

Fact Name	Details
Form Purpose	The DHCS 6207 is a Medi-Cal Disclosure Statement that applicants or providers must complete for enrollment or continued enrollment as Medi-Cal providers.
Consequences of Inaccuracy	New applicants may face denial of enrollment and a three-year reapplication bar for failing to provide complete and accurate information.
Reporting Requirements	The Department must report terminations to the Centers for Medicare and Medicaid Services, as mandated by federal law under 42 U.S.C. § 1396a(kk)(6).
Submission Guidelines	Applicants must submit the completed form without staples and ensure all corrections are made in ink, initialed and dated.
Governing Laws	This form is governed by the Code of Federal Regulations, Title 42, Part 455, and California Code of Regulations, Title 22, Sections 51000–51451.
Confidentiality	Disclosure of social security numbers is mandatory for individuals listed on the form, in accordance with privacy regulations.

California Dhcs: Usage Guidelines

Filling out the California DHCS form is a crucial step in the process of becoming or remaining a Medi-Cal provider. This form requires accurate and complete information to ensure compliance with state regulations. It’s important to carefully follow the instructions provided to avoid any potential delays or issues with your application.

Read the instructions thoroughly. Familiarize yourself with all sections of the form to understand what information is required.
Type or print clearly. Use black or blue ink to fill out the form, ensuring that all entries are legible.
Complete Section I. Provide your legal name as reported to the IRS, any existing provider numbers, and the address where services will be provided. Check “N/A” for any sections that do not apply to you.
Fill out Section II. If you are an unincorporated sole proprietor or an individual rendering provider, ensure that you disclose your social security number as required.
Provide ownership information in Section III. List all entities with managing control and their National Provider Identifiers (NPI). Be accurate and thorough.
Complete Section IV. Report any individuals with ownership or control interest in your application, including their NPIs.
Fill out Section V. Disclose any subcontractors or significant business transactions related to your practice.
Complete Section VI. Answer whether you provide incontinence supplies and fill out any necessary details if applicable.
Complete Section VII. If you are a pharmacy applicant or provider, ensure this section is filled out correctly.
Sign and date Section VIII. Your signature must be original, and if required, the form must be notarized. Ensure the legal name matches the application package.
Review the entire form. Check for any blank fields, and make corrections as needed by lining through the error, dating, and initialing in ink.
Submit the form. Return the completed form with your application package to the address specified in the instructions.

Your Questions, Answered

What is the purpose of the California DHCS form?

The California DHCS form, specifically the Medi-Cal Disclosure Statement (DHCS 6207), is essential for anyone applying to become a Medi-Cal provider. This form collects important information about the applicant or provider, ensuring compliance with state and federal regulations. It is a crucial part of the application package for enrollment, continued enrollment, or certification as a Medi-Cal provider.

Who needs to complete the DHCS 6207 form?

All applicants and providers must complete the DHCS 6207 form unless they qualify for specific exemptions. These exemptions include those 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” (DHCS 6219). It is important not to leave any sections blank and to indicate "N/A" where applicable.

What happens if I do not provide complete and accurate information?

Failure to disclose complete and accurate information can lead to serious consequences. For new applicants, this may result in a denial of enrollment and a three-year reapplication bar. For currently enrolled applicants, it could lead to denial, deactivation of all business addresses, and the same three-year reapplication bar. This emphasizes the importance of thoroughness when completing the form.

Are there specific instructions for completing the DHCS 6207 form?

Yes, specific instructions are provided to ensure the form is completed correctly. Applicants should read all instructions carefully, type or print clearly in ink, and avoid using staples or correction fluid. If corrections are necessary, they must be made by lining through the incorrect entry, dating, and initialing the change in ink. Following these guidelines helps prevent delays in processing your application.

What information is required regarding ownership interests?

Applicants must disclose information about ownership interests and managing control. This includes identifying individuals or entities with 5% or more ownership or control interest. The form requires details about direct and indirect ownership interests, which helps the Department of Health Care Services assess the applicant's business structure and compliance with regulations.

Is there a requirement for notarization of the DHCS 6207 form?

Yes, the DHCS 6207 form must be notarized, except for certain licensed applicants, such as physicians and dentists. For those who do need notarization, it is essential that the signature is original; stamped or photocopied signatures will not be accepted. This requirement adds a layer of verification to the application process.

What should I do if I have subcontractors?

If you have subcontractors, you must provide details about them in the application. A subcontractor is defined as any individual or organization to which you have delegated management functions or responsibilities related to healthcare services. This includes contracts for space, supplies, or services under the Medi-Cal Program. It is important to disclose any significant business transactions that exceed specified financial thresholds.

Where can I find more information about the Medi-Cal program?

For more information, applicants are encouraged to visit the Medi-Cal website at www.medi-cal.ca.gov. By clicking on the “Provider Enrollment” link, you can access additional resources and guidance related to the enrollment process, regulations, and requirements for Medi-Cal providers.

What should I do if I have questions while filling out the form?

If you encounter questions or uncertainties while completing the DHCS 6207 form, it is advisable to seek assistance. You can consult the instructions provided with the form or reach out to the Department of Health Care Services for clarification. Ensuring that you understand the requirements will help facilitate a smoother application process.

Common mistakes

Leaving Sections Blank: One common mistake is failing to fill out all sections of the form. Every question, box, and line must be addressed. If a question does not apply, simply check or write "N/A." Leaving sections blank can lead to delays or even denial of the application.
Incorrect Signature: Another frequent error involves the signature section. The form requires an original signature from an authorized individual, such as a sole proprietor or corporate officer. Stamped or photocopied signatures are not acceptable. This oversight can invalidate the entire application.
Failure to Provide Accurate Information: Applicants often underestimate the importance of accuracy. Any incomplete or incorrect information can result in severe consequences, including denial of enrollment and a three-year reapplication bar. It is crucial to double-check all entries before submission.
Improper Correction Methods: When making corrections on the form, it is essential to follow the specified method. Applicants should line through the incorrect entry, date, and initial the correction in ink. Using correction fluid or tape is strictly prohibited and can lead to complications.

Documents used along the form

The California DHCS form is a crucial document for applicants and providers seeking enrollment in the Medi-Cal program. Alongside this form, several other documents are commonly required to ensure a complete application package. Each document serves a specific purpose in the enrollment process, helping to establish compliance with state and federal regulations.

Medi-Cal Rendering Provider Application/Disclosure Statement (DHCS 6216): This form is specifically for rendering providers who are applying to join a group. It consolidates the application and disclosure requirements into one document, simplifying the process for eligible applicants.
Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement (DHCS 6219): This document is intended for providers who order, refer, or prescribe services under the Medi-Cal program. It ensures that these providers meet the necessary qualifications and comply with the program's standards.
Lease Agreement: If the applicant or provider leases the location where services are rendered, a current signed lease agreement must be included. This document verifies the legitimacy of the business premises and outlines the terms of the lease.
IRS Form 941 or Similar Documentation: This form is required for corporations with ownership or control interests in the applicant or provider. It provides proof of tax compliance and helps verify the financial standing of the entities involved.
Notarized Signature Page: For certain applicants, particularly Durable Medical Equipment providers and others, a notarized signature is necessary. This requirement adds an extra layer of verification to ensure the authenticity of the application.

Submitting all required forms and documents accurately is essential for a smooth enrollment process in the Medi-Cal program. Ensure that each document is complete and complies with the outlined requirements to avoid delays or denials in your application.

Similar forms

The California DHCS form, specifically the Medi-Cal Disclosure Statement (DHCS 6207), shares similarities with several other important documents used in healthcare and provider enrollment. Each of these documents serves a unique purpose but often requires similar types of information regarding applicants and providers. Here’s a list of eight documents that are comparable to the California DHCS form:

Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement (DHCS 6216) - This form is specifically for rendering providers who are applying to join a provider group. Like the DHCS 6207, it requires detailed information about ownership and control interests.
Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement (DHCS 6219) - This document is for providers who order, refer, or prescribe services under Medi-Cal. Similar to the DHCS 6207, it collects information about the provider's qualifications and affiliations.
National Provider Identifier (NPI) Application - The NPI application is essential for healthcare providers to obtain a unique identifier for billing purposes. It requires disclosure of ownership and control information, akin to what is required in the DHCS 6207.
Medicare Enrollment Application (CMS-855I) - This application is for individual healthcare providers enrolling in Medicare. It shares the need for comprehensive disclosure of ownership interests and business affiliations, similar to the Medi-Cal Disclosure Statement.
Medicare Provider Enrollment Application (CMS-855B) - This form is for organizations seeking to enroll in Medicare. Like the DHCS 6207, it requires detailed information about the organization’s structure and ownership.
California Department of Public Health (CDPH) Facility Licensing Application - Facilities seeking licensure must submit this application, which requires similar disclosures about ownership and management control as the DHCS 6207.
Provider Credentialing Application - Healthcare organizations often use this application to verify the credentials of their providers. It typically requests similar information regarding ownership and affiliations as found in the DHCS 6207.
Durable Medical Equipment (DME) Supplier Application - This application is necessary for suppliers of DME to enroll in Medi-Cal. It requires disclosure of ownership and control interests, mirroring the requirements of the DHCS 6207.

Understanding these documents can help applicants navigate the complexities of healthcare provider enrollment and ensure compliance with necessary regulations.

Dos and Don'ts

When filling out the California DHCS form, it is essential to follow specific guidelines to ensure a smooth application process. Below is a list of things you should and shouldn't do.

Do read all instructions carefully before starting the form.
Do type or print clearly in ink to ensure readability.
Do check or write "N/A" for any questions that do not apply to you.
Do initial and date any corrections made on the form in ink.
Don't leave any questions, boxes, or lines blank.
Don't use staples on the form or any attachments.
Don't use correction fluid or tape for any mistakes; simply line through and correct.
Don't submit the form without ensuring it is part of a complete application package.

Misconceptions

Understanding the California DHCS form can be challenging, and several misconceptions often arise. Here are four common misunderstandings:

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. Not submitting this form can lead to denial of enrollment.

Misconception 2: Only new applicants need to worry about providing accurate information.

In reality, both new and currently enrolled applicants must disclose complete and accurate information. Failing to do so can result in severe consequences, including denial of enrollment and a three-year reapplication bar.

Misconception 3: Corrections can be made easily on the DHCS form.

While corrections are allowed, they must be done correctly. You cannot use correction fluid or tape. Instead, you must line through the incorrect information, date it, and initial in ink.

Misconception 4: The form does not require notarization for all applicants.

This is only partially true. While some professionals, like physicians and dentists, are exempt from notarization, others, such as Durable Medical Equipment providers, must have their forms notarized. Always check the specific requirements for your profession.

Key takeaways

Key Takeaways for Completing the California DHCS Form

All applicants and providers must submit a current Medi-Cal Disclosure Statement (DHCS 6207) as part of their application package.
New applicants must provide complete and accurate information to avoid denial of enrollment and a three-year reapplication bar.
Corrections to the form should be made by lining through the incorrect information, dating, and initialing in ink. Avoid using correction fluid or staples.
Ensure that the legal name on the form matches the name on the associated application package, and an original signature is required.
Visit the Medi-Cal website for additional instructions and compliance regulations related to provider enrollment.