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Click ‘Get Form’ to open the dhcs 3076 in the editor.
Begin by filling out the 'General Information and Certification' section. Enter the facility name, service level, Medi-Cal provider number, and reporting period dates.
Proceed to Section A—Request for Information. Answer questions regarding financial statements and asset disposals by marking the appropriate boxes.
In Section B—Licensee Description, indicate the type of control and legal organization of your facility by placing an 'X' in the correct columns.
Complete Section C—Facility Census by entering licensed beds at both the beginning and end of the reporting period, along with client days, discharges, and admissions.
For Sections D through J, follow similar instructions to provide detailed information about related organizations, compensation details, income and expenses, reclassifications, and labor reports as required.

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