The California Department of Health Care Services (DHCS) form, known as the Medi-Cal Disclosure Statement (DHCS 6207), is a crucial document for applicants and providers seeking enrollment in the Medi-Cal program. This form requires comprehensive and accurate information to ensure compliance with federal and state regulations. Failing to provide complete details can lead to significant consequences, including denial of enrollment and a three-year reapplication bar. Fill out the form by clicking the button below.
The California Department of Health Care Services (DHCS) requires all applicants and providers to complete the Medi-Cal Disclosure Statement, known as DHCS 6207, as part of their enrollment process. This form serves multiple purposes, including ensuring that applicants provide complete and accurate information, which is critical for maintaining compliance with Medi-Cal regulations. New applicants must understand that failing to disclose accurate details can lead to denial of enrollment and a three-year reapplication bar. Similarly, current providers face consequences such as deactivation of their business addresses for inaccuracies. The form contains various sections, each designed to gather specific information about the applicant or provider, including ownership interests, managing control details, and any subcontractors involved. Clear instructions guide the completion of the form, emphasizing the importance of accuracy and the prohibition of using staples or correction fluids. Additionally, the form requires the applicant's legal name to match official documentation, and it must be signed by an authorized representative. Notarization is required for certain providers, while others may be exempt. Overall, the Medi-Cal Disclosure Statement is a crucial component of the enrollment process, ensuring that all relevant information is disclosed and verified in accordance with federal and state regulations.
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
i
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;
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.
iii
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.
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
F. “Doing Business As” name
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)
(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?
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)
Sole Proprietor (Unincorporated)
Limited Liability Company:
Governmental
Corporation
State of formation:
State incorporated:
(Enclose Articles of Incorporation and
Corporate number:
Statement of Information)
_____________________
Nonprofit:
Check one:
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).
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”).
1.
Full legal name of health care provider
2.
Address (number, street)
K.Respond to the following questions:
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?
If yes, provide the date of the conviction (mm/dd/yyyy):
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?
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?
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:
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:
CHECK
APPLICABLE
EFFECTIVE DATE(S) OF
DATE(S) OF REINSTATEMENT(S),
PROGRAM
SUSPENSION
AS APPLICABLE
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:
WHERE ACTION(S) WAS
TAKEN
ACTION(S) TAKEN
LICENSING AUTHORITY’S ACTION(S)
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
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:
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:
•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.
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)
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.
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
CONTROL
(IF APPLICABLE)
5.
6.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
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
Doing Business As (DBA) name (if applicable)
Primary Business Address (number, street) *
*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
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?
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?
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?
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:
5. Has this entity ever been suspended from a Medicare, Medicaid, or Medi-Cal program?
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)
Page 6 of 15
Completing the California DHCS form is essential for those seeking enrollment or certification as a Medi-Cal provider. Following the correct steps ensures that the application is processed efficiently. Here are the steps to fill out the Medi-Cal Disclosure Statement (DHCS 6207).
What is the California DHCS form?
The California DHCS form, specifically the Medi-Cal Disclosure Statement (DHCS 6207), is a required document for individuals and entities applying to become Medi-Cal providers. It collects essential information about the applicant’s business structure, ownership, and any affiliations that may impact their eligibility for the Medi-Cal program.
Who needs to complete the DHCS 6207 form?
All applicants or providers looking to enroll, maintain enrollment, or get certified as Medi-Cal providers must complete this form. This includes new applicants as well as those who are currently enrolled. Failure to provide complete and accurate information can lead to denial of enrollment and other penalties.
What happens if I do not disclose complete information?
Not disclosing complete and accurate information can have serious consequences. For new applicants, it may result in denial of enrollment and a three-year reapplication bar. Current providers may face deactivation of their business addresses and similar reapplication restrictions. Additionally, the Department of Health Care Services is required to report terminations to federal and state agencies.
How should I fill out the DHCS 6207 form?
When completing the form, it is crucial to read all instructions carefully. Use clear, typed, or handwritten responses in ink. Avoid leaving any sections blank; if a question does not apply, indicate this by writing “N/A.” If corrections are needed, cross out the incorrect entry, date, and initial the change in ink. Do not use correction fluid or staples.
What are the penalties for submitting incorrect information?
Submitting incorrect information can lead to severe penalties, including denial of your application, deactivation of your provider status, and a three-year bar on reapplying. Moreover, any misrepresentation can result in legal actions and reporting to relevant authorities.
Is notarization required for the DHCS 6207 form?
Yes, the form must be notarized, except for certain licensed professionals like physicians and dentists. For those who do need to notarize, ensure that the signature on the form is original, as stamped or photocopied signatures are not accepted.
What information is required regarding ownership and control?
The form requires detailed information about ownership interests and managing control. This includes listing any individuals or entities with a 5% or more ownership interest, as well as providing their National Provider Identifier (NPI). It is important to accurately report all ownership interests, both direct and indirect, to comply with regulations.
Where can I find more information about the Medi-Cal program?
For additional details about the Medi-Cal program and the enrollment process, you can visit the official Medi-Cal website at www.medi-cal.ca.gov. There, you can find resources and links related to provider enrollment and other relevant topics.
Filling out the California DHCS form can be a straightforward process, but many people make common mistakes that can lead to delays or denials. One frequent error is leaving sections blank. Every question must be answered. If something doesn’t apply to you, simply write “N/A.” This small step ensures your application is complete and helps avoid unnecessary back-and-forth communication with the Department of Health Care Services.
Another mistake often seen is the use of correction fluid or tape. If a correction is needed, applicants should line through the error, date it, and initial it in ink. This keeps the form clean and clear. Using correction fluid can create confusion and might even lead to the application being rejected.
People sometimes forget to include necessary attachments. For instance, if you're leasing a location, a signed lease agreement must accompany your application. Missing documentation can stall the process and might even result in denial. Always double-check that all required documents are included before submission.
Lastly, many applicants overlook the importance of signatures. The signature must be from someone authorized to bind the applicant legally, and it must be original. Stamped or photocopied signatures are not acceptable. Missing or incorrect signatures can lead to significant delays, so it’s crucial to ensure this step is done correctly.
When applying to become a Medi-Cal provider in California, completing the DHCS Disclosure Statement (DHCS 6207) is just one part of the process. Several other forms and documents may also be required to ensure compliance and a smooth application experience. Here’s a list of some common documents that often accompany the DHCS form:
Submitting the correct forms and supporting documents is vital for a successful application to become a Medi-Cal provider. Each document plays a specific role in verifying compliance with state and federal regulations, ensuring that applicants are adequately prepared to serve Medi-Cal beneficiaries.
The California DHCS form, specifically the Medi-Cal Disclosure Statement (DHCS 6207), shares similarities with several other important documents. Each of these documents serves a distinct purpose in the healthcare and provider enrollment process. Below is a list of ten documents that are comparable to the California DHCS form:
When filling out the California DHCS form, there are specific actions to take and avoid to ensure a smooth application process. Here is a list of five things you should and shouldn't do:
Misconceptions about the California DHCS form can lead to confusion and potential issues during the application process. Below are six common misconceptions, along with clarifications to help ensure a smoother experience.
Understanding these misconceptions can help applicants navigate the process more effectively. Ensuring that all instructions are followed will contribute to a smoother enrollment experience with Medi-Cal.
Key Takeaways for Filling Out the California DHCS Form