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Fill a Valid California Dhcs Form

The California DHCS form, formally known as the Medi-Cal Disclosure Statement (DHCS 6207), is a critical document that must be completed and submitted by anyone applying for or currently enrolled in the Medi-Cal program as a provider. This comprehensive form plays a significant role in the application process for enrollment, continued enrollment, or certification as a Medi-Cal provider. With stringent requirements, the form emphasizes the importance of disclosing complete and accurate information, as failure to do so may lead to denial of enrollment, deactivation of business addresses, and a mandatory three-year reapplication bar for both new and currently enrolled applicants.

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Article Guide

In the realm of healthcare services in California, the Medi-Cal Disclosure Statement, identified by its form number DHCS 6207, plays a pivotal role. This document is essential for every applicant or provider wishing to enroll, continue enrollment, or certify as a Medi-Cal provider under the auspices of the State of California—Health and Human Services Agency and the Department of Health Care Services. Completing this form accurately and truthfully is not merely a procedural step but a requirement underscored by serious implications for non-compliance. For new applicants, omission or misrepresentation of information can lead not only to a denial of enrollment but also to a prohibition on reapplication for three years. Similarly, for those already enrolled, such failures can result in deactivation of business addresses and the same three-year reapplication bar, alongside the potential reporting of their termination from Medi-Cal to relevant federal and state bodies. The form itself requires careful attention to detail, urging applicants to avoid staples, use ink for any corrections and ensure completeness in every section—from individual or group provider information, through disclosures about ownership interests and managerial control, to details concerning subcontractors and significant business transactions. With regulations and instructions spread across its extensive content, the DHCS 6207 form is a comprehensive document designed to ensure transparency and compliance within the Medi-Cal program.

Document Example

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

Click for PDF Form

Form Breakdown

Fact Number	Fact Name	Description
1	Form Identity	The form is identified as DHCS 6207, a Medi-Cal Disclosure Statement required by the Department of Health Care Services.
2	Form Purpose	Used by applicants or providers for enrollment, continued enrollment, or certification as a Medi-Cal provider.
3	Completion Requirement	Returning a complete and accurate Medi-Cal Disclosure Statement is mandatory.
4	Submission Instructions	Instructions include completing all sections, printing clearly in ink, not using staples, and avoiding correction fluid.
5	Non-compliance Consequences	Failure to disclose complete and accurate information may lead to denial or deactivation of enrollment and a three-year reapplication bar.
6	Reporting Requirements	Terminations must be reported to the Centers for Medicare and Medicaid Services and to other States’ Medicaid and Children’s Health Insurance Programs.
7	Governing Laws	Subject to regulations under Code of Federal Regulations, Title 42, Parts 455; California Code of Regulations, Title 22, Sections 51000–51451; and Welfare and Institutions Code, Sections 14043–14043.75.
8	Special Sections for Different Applicants	The form includes sections tailored to individual providers, entities, sole-proprietors, pharmacies, etc.
9	Modification Instructions	Corrections on the form must be initialed and dated by the applicant or provider in ink.

How to Write California Dhcs

Filling out the California DHCS form is an essential step for applicants or providers seeking enrollment, certification, or continued enrollment as a Medi-Cal provider. Accuracy and completeness are crucial while filling out this form, as any incomplete or inaccurate information may lead to application denial and a possible three-year reapplication bar. Follow every instruction carefully, print clearly in ink, and avoid using staples. If corrections are required, ensure they are initialed and dated. Diligently reviewing each section and attaching all necessary documentation will streamline the application process. Below are step-by-step instructions to accurately complete this form:

Ensure all applicant/provider information is complete. For fields not applicable, mark "N/A". Do not leave any section blank.
Section I: Applicant/Provider Information
1. Enter the legal name of the applicant/provider as reported to the IRS.
2. Specify the legal name as it appears on the professional license if applicable, or check "N/A" if not.
3. List all existing provider numbers used at the indicated address or check "N/A" if not applicable.
4. If applying as a rendering provider to a provider group, indicate by checking the designated box and proceed as instructed.
5. Fill in the fictitious business name and "Doing Business As" name if applicable or mark "N/A".
6. Provide the address where services are rendered or provided, including ZIP code.
7. Answer whether the applicant/provider leases the location and complete the additional information regarding the lessor if applicable.
8. Select the type of entity and provide additional documentation if required (Partnership Agreement, Articles of Incorporation, etc.).
9. List fines or debts owed by the applicant/provider to governmental agencies related to healthcare programs and the arrangements made to fulfill these obligations.
Sections II to VII: Follow the specific instructions provided in each section carefully, focusing on the applicable areas based on the applicant's or provider's status, type of ownership, and services provided. For pharmacy applicants, be diligent in completing Section VII thoroughly.
Section VIII: Declaration and Signature Page
1. Ensure the legal name of the applicant/provider matches the name on the associated application package.
2. Have the form signed by an individual with authority to legally bind the applicant or provider. An original signature is required.
3. If applicable, have the Disclosure Statement notarized, unless exempted by the applicant's or provider's professional status as outlined in the instructions.

Upon completion, review the form to ensure all information is accurate and that any required attachments are included. Submit the completed form along with the full application package to the address specified on the application form. Carefully following these instructions will help ensure the process moves forward without unnecessary delays.

Listed Questions and Answers

What is the DHCS 6207 form used for in California?

The DHCS 6207 form, also known as the Medi-Cal Disclosure Statement, is a required document for anyone applying to become a new provider, continuing enrollment, or seeking certification as a Medi-Cal provider in California. Its main purpose is to disclose complete and accurate information about the applicant or provider to the Department of Health Care Services. Submitting a complete and accurate form is crucial. Failing to do so may lead to the denial of enrollment and the imposition of a three-year reapplication bar for new applicants or the deactivation of business addresses for currently enrolled providers.

What happens if I do not provide complete and accurate information on the DHCS 6207 form?

If you fail to provide complete and accurate information on the DHCS 6207 form, there are significant consequences. For new applicants, this can result in a denial of enrollment and a three-year bar from reapplying. For those already enrolled, it may lead to denial and deactivation of all business addresses associated with the Medi-Cal program. Additionally, the Department of Health Care Services is obligated to report the termination of participation to the Centers for Medicare and Medicaid Services as well as to Medicaid and Children's Health Insurance Programs in other states.

How should corrections be made on the DHCS 6207 form?

If you need to make corrections on the DHCS 6202 form, you should clearly line through the incorrect entry, write the correct information, and then initial and date the correction using ink. It is important not to use correction fluid, correction tape, pencil, highlighter pens, or any method that can be easily altered. Ensuring the modifications are clearly documented helps maintain the integrity of the information provided.

Are there specific formatting requirements for submitting the DHCS 6207 form?

Yes, there are specific formatting requirements you must follow when completing the DHCS 6207 form:

The form and any attachments should be typed or printed clearly in ink.
Staples must not be used on the form or any attachments.
All questions, boxes, and lines must be completed; if a section does not apply, mark it with “N/A”.
An original signature is required on the declaration and signature page, as stamped, faxed, and/or photocopied signatures are not acceptable.

These requirements ensure the document is legible and properly processed.

What are the next steps after completing the DHCS 6207 form?

After completing the DHCS 6207 form, you should include it as part of a complete application package for enrollment, continued enrollment, or certification as a Medi-Cal provider. Ensure that you have followed all formatting and submission guidelines detailed in the form's instructions. The completed form, along with the full application package, must be sent to the address listed on the application form. It is advisable to review the entire package for accuracy and completeness before submission to avoid potential delays or denial due to missing or inaccurate information.

Common mistakes

Filling out the California Department of Health Care Services (DHCS) form is a critical step for applicants or providers seeking enrollment, continued enrollment, or certification as a Medi-Cal provider. However, errors can compromise the accuracy and completeness of the application, potentially leading to denial, deactivation, or other penalties. Here are seven common mistakes to avoid:

Leaving fields blank: All questions, boxes, lines, etc., should be answered. If a particular section doesn't apply, check or write “N/A” instead of leaving it empty.
Improper corrections: If a mistake is made, the correct method is to line through the error, then date and initial in ink. Using pencils, correction fluid, or correction tape is not acceptable.
Stapling documents: Staples should not be used on the form or any attachments. This instruction is often overlooked, leading to processing delays.
Missing documentation for leased locations: If the applicant leases the location where services are rendered, a current signed lease agreement must be enclosed. Failure to attach this document can cause processing issues.
Incorrectly reporting ownership interest: Accurately reporting ownership interest and/or managing control information is critical. Mistakes in calculating the percentage of ownership or neglecting to include indirect ownership interests are common errors.
Failing to provide required identification numbers: Each entity with 5% or more ownership or control interest must have their National Provider Identifier (NPI) listed. Omissions can lead to the application being flagged for review.
Signatures not meeting requirements: The signature section must be completed by an authorized individual with a proper understanding of their legal bind. Stamped, faxed, and/or photocopied signatures are not acceptable, and the declaration must be notarized unless exempt.

Ensuring accuracy and completeness when filling out the DHCS 6207 form is paramount. Applicants and providers should pay close attention to details, carefully review all instructions provided, and submit a complete application package to avoid delays or denial of enrollment and certification.

Documents used along the form

When submitting the California DHCS form, it's essential to ensure all necessary accompanying documents are in place to prevent any potential delays in processing. These additional documents play a crucial role in the enrollment and certification processes for Medi-Cal providers. Here are seven other important forms and documents often required alongside the DHCS 6207 form:

Business License: Verifies that the business is legally recognized in the state or municipality. This is essential for proving that a provider operates a legitimate business.
Professional License: Demonstrates the provider's qualifications and legal authorization to provide healthcare services. Specific professional licenses must align with the services offered.
IRS Form W-9 (Request for Taxpayer Identification Number and Certification): Used to provide the correct taxpayer identification number (TIN) to the payer for reporting purposes, ensuring accurate tax reporting.
Medi-Cal Provider Agreement: An agreement between the provider and the Department of Health Care Services (DHCS), outlining the terms and conditions under which the provider will participate in Medi-Cal.
Proof of Insurance: Confirms that the provider has adequate malpractice and liability insurance, protecting both the provider and patients.
Lease Agreement: For those who lease their business location, a copy of the lease validates the address and terms under which they operate.
Disclosure of Ownership and Control Interest Statement: Identifies individuals or entities with an ownership or control interest in the provider's practice, ensuring transparency and compliance with regulatory requirements.

The combination of these documents with the DHCS form creates a comprehensive application package that meets regulatory standards and supports the provider's request for enrollment, re-enrollment, or certification. It's imperative to review each document for accuracy and completeness before submission to avoid any potential setbacks in the approval process.

Similar forms

The California Medi-Cal Physician Application (DHCS 9096) shares many commonalities with the DHCS 6207 form. Both documents are integral to the enrollment and credentialing process for healthcare providers seeking to participate in the state's Medi-Cal program. Each form necessitates detailed information about the provider, including personal identification, professional qualifications, and practice specifics. An emphasis on accurate and comprehensive disclosure is common to both, underlining the State's commitment to preventing fraud and ensuring quality care for Medi-Cal beneficiaries.

The Provider Enrollment Application (CMS-855A) for Medicare shares similarities with California's DHCS 6207, particularly in its function and requirement for exhaustive disclosure of provider information. Both forms are designed to vet providers for government-funded healthcare programs, aiming to ensure suitability, prevent fraud, and maintain high standards of care. They require detailed information on ownership, practice locations, and legal compliance, placing a significant emphasis on transparency and accountability.

The National Provider Identifier (NPI) Application/Update Form (CMS-10114) resembles the DHCS 6207 in its aim to collect provider details for identification purposes within government healthcare programs. While the DHCS 6207 encompasses broad disclosures for Medi-Cal enrollment, the NPI form focuses on assigning a unique identifier to each provider. However, both forms are critical for the administrative organization and claim processing within federal and state healthcare programs, emphasizing the need for accurate provider information.

The California State Board of Pharmacy's Pharmacy License Application process is analogous to the DHCS 6207's section specific to pharmacy applicants. Both demand comprehensive data on the pharmacy's ownership, location, and managing personnel. This scrutiny ensures that only qualified entities dispense medications to Medi-Cal beneficiaries, emphasizing safeguarding patient safety and compliance with regulatory standards.

The IRS Form W-9, Request for Taxpayer Identification Number and Certification, and the DHCS 6207 share the necessity for accurate taxpayer identification. Providers on the DHCS 6207 form must disclose their tax identification numbers (TINs) for purposes similar to those sought by the IRS Form W-9, including tax compliance and anti-fraud measures. These forms play crucial roles in the financial integrity and transparency of healthcare and other financial transactions.

The Health Insurance Portability and Accountability Act (HIPAA) Compliance Forms have a thematic connection to the DHCS 6207, particularly regarding data accuracy and legal adherence. Both sets of documents emphasize the importance of safeguarding patient information, adhering to state and federal regulations, and ensuring participants in healthcare delivery are credible and compliant with pertinent laws and ethical standards.

The Child Health and Disability Prevention (CHDP) Program Provider Application form shares the objective of the DHCS 6207 form in qualifying healthcare providers for participation in a specific state healthcare program. Both applications assess the provider's ability to comply with program standards and regulations, ensuring that beneficiaries receive high-quality care. These forms serve as gatekeepers, ensuring only qualified and credible providers serve vulnerable populations.

The California Department of Social Services Community Care Licensing Application for a Facility License is similar to the DHCS 6207 in its rigorous assessment of the applicant's qualifications and regulatory compliance. Although targeting different provider sectors within the healthcare system, both applications emphasize safety, quality of care, and adherence to stringent state regulations to protect consumers.

The Drug Enforcement Administration (DEA) Registration Form (DEA Form 224) for prescribing controlled substances echoes portions of the DHCS 6207 related to legal compliance and operational legitimacy. While the DEA form is specific to controlled substance management, both forms serve as critical components in the regulatory landscape, ensuring healthcare providers operate within legal bounds and maintain high ethical standards.

Lastly, the California Department of Public Health Licensing and Certification Application shares its core purpose with the DHCS 6207. Both are critical in the state's efforts to regulate healthcare providers, ensuring they meet specific operational, safety, and quality standards. The comprehensive review process delineated in both applications underscores California's commitment to maintaining a credible, competent healthcare provider network for public and government-sponsored programs.

Dos and Don'ts

When completing the California Department of Health Care Services (DHCS) form, there are crucial dos and don'ts that applicants and providers should consider to avoid common errors and ensure the process is completed efficiently and accurately. Below is a helpful list of best practices:

Things You Should Do:

Read all the instructions provided in the form carefully before starting to fill it out.
Type or print clearly in ink to ensure all information is legible.
Ensure completeness by filling out every question, box, or line; if something does not apply, write "N/A" for not applicable.
When corrections are needed, line through the error, then date and initial the correction in ink.
Securely attach documents to the form without using staples, opting for paper clips instead if needed.
Include a copy of the current signed lease agreement if you lease the location where services are provided.
Return the completed disclosure statement with the complete application package to the listed address.

Things You Shouldn't Do:

Do not leave any questions, boxes, lines, etc., blank without indicating if they are not applicable.
Do not use staples to attach any documents or forms, including attachments.
Do not use a pencil, correction tape, correction fluid, or highlighter pen on the form.
Do not ignore the requirement to attach a lease agreement if applicable.
Do not overlook the need to ensure the legal name of the applicant/provider matches across documents.
Do not submit without checking the accuracy and completeness of every section relevant to your situation.
Do not forget to obtain an original signature where required; stamped, faxed, and photocopied signatures are not accepted.

Adherence to these guidelines will help ensure the successful submission of the California DHCS form, reducing the likelihood of delays or issues in the enrollment, continued enrollment, or certification as a Medi-Cal provider.

Misconceptions

There are many misconceptions about the California DHCS form, specifically the Medi-Cal Disclosure Statement (DHCS 6207), that need to be clarified:

Only medical doctors need to complete it: Every applicant or provider, not just medical doctors, must complete and submit a current Medi-Cal Disclosure Statement as part of their application package for enrollment, continued enrollment, or certification as a Medi-Cal provider.
It's optional to fill out the form completely: Leaving sections blank can result in denial or deactivation of enrollment. It's important to fill out every required section, marking “N/A” where something does not apply.
It's okay to use staples: The form specifically prohibits the use of staples on it or any attachments, to maintain the integrity and readability of the documents.
Correction fluid is permitted for corrections: Correction fluid, tape, or similar products are not allowed. Corrections must be made by lining through the error, then dating and initialing the change in ink.
The form can be signed by anyone in the organization: The form must be signed by an individual with legal authority to bind the applicant or provider, such as a sole proprietor, partner, corporate officer, or official representative.
Stamped or digital signatures are acceptable: An original, hand-written signature is required; stamped, faxed, and/or photocopied signatures are not permitted.
Notarization is always required: Not every applicant/provider needs to notarize this form. Providers licensed under specific divisions described in the Business and Professions Code do not need to.
It's just a formality with no real consequences: Failure to disclose complete and accurate information can lead to denial or deactivation of enrollment and imposition of a three-year reapplication bar, significantly impacting the ability to provide services.
All sections apply to every applicant/provider: Some sections may not apply, depending on the type of provider or the organization's structure. However, instructions must be read carefully to determine applicability.
It's only submitted once: The form needs to be submitted with the initial application package and may need to be resubmitted or updated for continued enrollment or changes in the provider's information or status.

Understanding these points ensures that applicants and providers correctly complete and submit the Medi-Cal Disclosure Statement (DHCS 6207), facilitating their enrollment process with the Department of Health Care Services.

Key takeaways

Here are key takeaways that applicants and providers in California should consider when completing and submitting the Department of Health Care Services (DHCS) Form 6207, an essential part of the application package for Medi-Cal:

Every applicant or provider must submit a current Medi-Cal Disclosure Statement (DHCS 6207) as a vital component of their Medi-Cal enrollment, re-enrollment, or certification.
New applicants should note that failing to provide complete and accurate information could lead to enrollment denial and a three-year bar on reapplication.
For currently enrolled providers, incomplete or inaccurate information may result in denial and deactivation of all business addresses, alongside a three-year reapplication bar.
The form requires that all applicants and providers do not leave any section blank, endorsing "N/A" where necessary, and corrections must be initialed and dated in ink—correction fluids or tapes are not acceptable.
Submitting a complete and accurate Disclosure Statement is mandated. Applicants and providers must comply with all Medi-Cal regulations as stipulated in Title 22 and the Welfare and Institutions Code.
Special attention should be paid to sections dealing with ownership interest, managing control information for both entities and individuals, indicating the rigorous checks on the background and affiliations of applicants.
In scenarios where services are provided at a leased location, attaching a current signed lease agreement is compulsory.
Disclosure of the Social Security Number (SSN) is mandatory for individual providers as per the Privacy Statement outlined in the document.
The document also covers guidelines for subcontractors and significant business transactions, emphasizing the transparency in operations and financial dealings related to Medi-Cal.
Finally, the declaration and signature page must be completed by an authorized individual, with an original signature, ensuring that all the information provided is accurate and truthful. Notarization is necessary for certain providers.

It is imperative for applicants and providers to review the entire document carefully, follow the instructions to the letter, and ensure that all provided information is complete and accurate to avoid any potential issues in the enrollment process.

For further assistance and more detailed information, visiting the Medi-Cal website is recommended.

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