The California DHCS form, officially known as the Medi-Cal Disclosure Statement (DHCS 6207), is a crucial document required for applicants and providers seeking enrollment or continued participation in the Medi-Cal program. This form must be completed accurately to avoid potential denial of enrollment and other penalties. For those interested in applying, fill out the form by clicking the button below.
The California Department of Health Care Services (DHCS) requires every applicant or provider to complete the Medi-Cal Disclosure Statement, also known as DHCS Form 6207, as part of the enrollment process for Medi-Cal providers. This form plays a critical role in ensuring compliance with state and federal regulations, safeguarding the integrity of the Medi-Cal program. It is essential for both new applicants and currently enrolled providers to understand the implications of submitting accurate and complete information. Failure to do so can lead to serious consequences, including denial of enrollment and a three-year reapplication bar. The form includes various sections that collect vital information, such as applicant details, ownership interests, managing control information, and any subcontractor arrangements. Specific instructions guide applicants on how to fill out the form correctly, emphasizing the importance of clarity and accuracy. For example, applicants must avoid leaving any questions unanswered and are instructed to make corrections by initialing and dating changes in ink. Additionally, the form outlines the necessary documentation that must accompany the application, including lease agreements for leased properties and details regarding significant business transactions. Understanding these requirements is crucial for applicants to navigate the enrollment process smoothly and maintain compliance with Medi-Cal 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 an essential step for anyone looking to enroll or maintain their status as a Medi-Cal provider. Following the correct procedures ensures that your application is processed smoothly. Here are the steps to fill out the form accurately.
The California DHCS form, specifically the Medi-Cal Disclosure Statement (DHCS 6207), is essential for all applicants and providers seeking enrollment, continued enrollment, or certification as Medi-Cal providers. This form ensures that all relevant and accurate information is disclosed, which is crucial for compliance with federal and state regulations.
Every applicant or provider must complete the DHCS 6207 form. This requirement applies to new applicants as well as currently enrolled providers. However, certain exceptions exist for those eligible to use different forms, such as the “Medi-Cal Rendering Provider Application” or the “Medi-Cal Ordering/Referring/Prescribing Provider Application.” It’s important to check eligibility before proceeding.
Failure to disclose complete and accurate information can lead to severe consequences. For new applicants, it may result in denial of enrollment and a three-year reapplication bar. Current providers may face denial, deactivation of all business addresses, and the same three-year reapplication bar. Such actions are reported to the Centers for Medicare and Medicaid Services and other relevant state programs.
If corrections are necessary, do not use correction fluid or tape. Instead, line through the incorrect entry, date it, and initial the correction in ink. This ensures that the changes are clear and verifiable, maintaining the integrity of the submitted information.
Yes, the form must be notarized, except for specific licensed professionals such as physicians, dentists, and certain healthcare providers. For those required to notarize, it is crucial that the signature is original; stamped or photocopied signatures will not be accepted.
Not submitting the DHCS 6207 form with your application package can lead to delays in processing or outright denial of your application. The form is a critical component of the application, and missing it means that your application is incomplete.
Yes, applicants must read all instructions carefully. It’s important to type or print clearly in ink, avoid leaving any sections blank, and check “N/A” where applicable. Additionally, do not use staples on the form or any attachments, as this can hinder processing.
For further details, applicants and providers can visit the Medi-Cal website at www.medi-cal.ca.gov . There, you can access resources related to provider enrollment and other important information regarding the Medi-Cal program.
Leaving Questions Blank: Many applicants forget to answer all questions. It's crucial to ensure that no boxes, lines, or questions are left unanswered. If a question does not apply, simply mark it as "N/A."
Using Correction Fluid: Some individuals attempt to correct mistakes with correction fluid or tape. This is not allowed. Instead, any corrections should be lined through, dated, and initialed in ink.
Incorrect Signature: The signature must come from an authorized individual, such as a sole proprietor or corporate officer. Stamped or photocopied signatures will not be accepted, leading to delays or denials.
Not Including Required Attachments: Failure to attach necessary documents, such as a current signed lease agreement, can result in a complete application being rejected. Always double-check that all required documents are included.
Inaccurate Information: Providing incorrect or incomplete information can lead to serious consequences, including denial of enrollment. Take the time to review all details for accuracy before submission.
Ignoring Formatting Instructions: Applicants often overlook the requirement to type or print clearly in ink. This can make the form difficult to read, potentially causing processing issues.
Neglecting Notarization: Certain applicants must have their Disclosure Statement notarized. Failing to do so, especially for those who require notarization, can lead to application denial.
The California Department of Health Care Services (DHCS) form is a critical document for Medi-Cal applicants and providers. However, it is often accompanied by several other forms and documents that play essential roles in the application and enrollment process. Below is a list of common forms and documents used alongside the DHCS form, each serving specific purposes in ensuring compliance and facilitating the enrollment process.
These forms and documents are essential for a comprehensive application package. Submitting them correctly helps streamline the enrollment process and ensures compliance with state and federal regulations. Careful attention to detail is crucial, as incomplete or inaccurate submissions can lead to delays or denials in enrollment.
The Medi-Cal Rendering Provider Application/Disclosure Statement (DHCS 6216) is closely related to the California DHCS form. Like the DHCS 6207, it is designed for healthcare providers seeking enrollment in the Medi-Cal program. This form is specifically for rendering providers who are part of a group practice. It simplifies the application process by allowing these providers to disclose necessary information without duplicating details already provided by the group. The emphasis on accurate disclosures and compliance with regulations mirrors the strict requirements found in the DHCS 6207.
The Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement (DHCS 6219) also shares similarities with the California DHCS form. This document is intended for providers who primarily order, refer, or prescribe services for Medi-Cal beneficiaries. Similar to the DHCS 6207, it requires comprehensive disclosure of ownership interests and managing control. Both forms aim to ensure that the information provided is complete and accurate, as inaccuracies can lead to severe consequences, including denial of enrollment.
The Medicare Enrollment Application (CMS-855I) is another document that serves a similar purpose. This application is required for individual healthcare providers who wish to enroll in the Medicare program. Like the DHCS 6207, the CMS-855I demands detailed information about ownership and managing control. Both documents stress the importance of transparency and accurate reporting, as errors can result in delays or denials of enrollment.
The National Provider Identifier (NPI) Application (CMS-10114) is akin to the California DHCS form in that it facilitates the identification of healthcare providers. While the NPI application focuses on obtaining a unique identifier for billing purposes, it also requires information about ownership and control similar to the DHCS 6207. Both forms emphasize the need for accurate disclosures to maintain compliance with federal regulations.
The Medicaid Provider Application in other states often resembles the California DHCS form. Each state has its own version, but the core requirements for disclosure of ownership, managing control, and compliance with state regulations are common themes. These applications, like the DHCS 6207, aim to ensure that all providers meet the necessary qualifications and standards before being allowed to participate in the Medicaid program.
The Provider Enrollment Application for the Children’s Health Insurance Program (CHIP) is another document that aligns with the California DHCS form. CHIP requires similar disclosures about ownership and control to ensure compliance with federal and state guidelines. Both forms aim to protect the integrity of healthcare programs by ensuring that only qualified providers are enrolled and that they adhere to the necessary regulations.
The Durable Medical Equipment (DME) Supplier Application also shares similarities with the DHCS 6207. This application is specific to suppliers of medical equipment and requires detailed disclosures about ownership and business practices. Like the DHCS form, it emphasizes the importance of accurate reporting to avoid penalties or denial of enrollment.
Lastly, the Home Health Agency Application is comparable to the California DHCS form. This application requires agencies to disclose information about ownership, control, and operational management. Both documents focus on ensuring that providers meet the necessary standards and regulations to deliver services to beneficiaries, reinforcing the importance of transparency and compliance in the healthcare sector.
Things You Should Do:
Things You Shouldn't Do:
This is not true. 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 can lead to denial of enrollment.
Both new and currently enrolled applicants must provide complete and accurate information. If current providers fail to disclose necessary details, they risk denial and deactivation of their business addresses.
This is incorrect. If corrections are needed, applicants must line through the error, date, and initial the change in ink. Using correction fluid or tape is not allowed.
While most sections require completion, certain parts may be left blank if they do not apply. Applicants should check or write “N/A” for any non-applicable sections to avoid confusion.
Key Takeaways for Filling Out and Using the California DHCS Form: