Dhcs 6207-2026

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The document outlines the requirements for completing and submitting a Medi-Cal Disclosure Statement (DHCS 6207) for applicants or providers seeking enrollment or continued participation in the Medi-Cal program in California. It emphasizes the necessity of providing complete and accurate information, detailing consequences for non-compliance, including denial of enrollment and reapplication bars. The document includes sections on applicant/provider information, ownership interests, managing control details, subcontractor information, and specific instructions for various types of providers. It also highlights legal obligations under federal and state regulations.

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Click ‘Get Form’ to open the DHCS 6207 in the editor.
Begin with Section I: Applicant/Provider Information. Fill in your legal name as reported to the IRS, and ensure all fields are completed without leaving any blank. If not applicable, check 'N/A'.
Proceed to Section II if you are an unincorporated sole-proprietor or individual rendering provider. Provide your full legal name, residence address, and social security number.
In Section III, list all entities with a 5% or more ownership interest. Ensure you attach any required documents such as partnership agreements or articles of incorporation.
Complete Sections IV through VIII by providing detailed information about ownership interests, subcontractors, and signing the declaration page. Remember to initial any corrections made in ink.

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Versions	Form popularity	Fillable & printable
2014	4.9 Satisfied (212 Votes)
2011	4.2 Satisfied (53 Votes)

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