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Medi-Cal Disclosure Statement DHS-6207 - California
| Medi-Cal Disclosure Statement Form. This is a California form and can be used in Medi Cal Statewide . |
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State of California--Health and Human Services Agency Department of Health Care Services Every applicant or provider must complete and submit a current Medi-Cal Disclosure Statement (DHCS 6207) as part of a complete application package for enrollment, continued enrollment, or certification as a Medi-Cal provider. Important: x 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. x 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. x x x x x 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. form. x Return this completed statement with the complete application package to the address listed on the application Overall Authority: Code of Federal Regulations, Title 42; Section 455; California Code of Regulations, Title 22, Sections 5100051451; Welfare and Institutions Code, Sections 1404314043.75 DHCS 6207 (Rev. 11/11) American LegalNet, Inc. www.FormsWorkFlow.com TABLE OF CONTENTS GENERAL INSTRUCTIONS ............................................................................................................................... I. II. III. IV. V. VI. VII. VIII. APPLICANT/PROVIDER INFORMATION ........................................................................................... UNINCORPORATED SOLE-PROPRIETOR OR INDIVIDUAL RENDERING PROVIDER ADDING TO A GROUP ........................................................................................................................ OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ENTITIES) ................. OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) .......... SUBCONTRACTOR .............................................................................................................................. INCONTINENCE SUPPLIES ................................................................................................................. PHARMACY APPLICANTS OR PROVIDERS ...................................................................................... DECLARATION AND SIGNATURE PAGE .......................................................................................... ii 1 4 5 7 10 13 14 15 DHCS 6207 (Rev. 11/11) i American LegalNet, Inc. www.FormsWorkFlow.com GENERAL INSTRUCTIONS FOR COMPLETING THE MEDI-CAL DISCLOSURE STATEMENT x x x x x DO NOT USE staples on this form or on any attachments. Do not use a pencil, correction tape, white out, highlighter pen, etc. on this form. If you must correct an entry, the applicant or provider must initial and date the correction in ink. Do not leave any questions, boxes, lines, etc., blank. To review the Title 22 provider enrollment regulations, please visit the Medi-Cal Website (www.medi-cal.ca.gov) and click the "Provider Enrollment" link. It is the responsibility of the applicant/provider to comply with all regulations pertaining to Medi-Cal. Section I: Applicant/Provider Information 1. All applicants and providers must complete this Section unless they are eligible to use the "Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers" (DHCS 6216). 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 EH blank if part D is checked. Section II: Unincorporated Sole-Proprietor or Individual Rendering Provider Adding to a Group Disclosure of social security number is optional. (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. 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. 3. Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity. 4. All entities with managing control of applicant/provider must be listed in this Section. 5. 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. 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. All management employees must be included in this section. 4. Disclosure of social security number is optional. (See Privacy Statement at bottom of page 15) Section V: Subcontractor 1. "Indirect ownership interest" means an ownership interest in any entity that has an ownership interest in the applicant or provider. This term
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