Dhcs 3076 2011 form-2026

The document is a Medi-Cal Program Cost Report for Intermediate Care Facilities for the Developmentally Disabled in California. It outlines the requirements for reporting financial information related to services provided, including details on facility operations, income and expenses, and necessary certifications. The report must be completed for each licensed facility and submitted within five months after the fiscal year ends, ensuring compliance with state regulations.

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Click ‘Get Form’ to open the dhcs 3076 2011 form in the editor.
Begin by filling out the 'General Information and Certification' section. Enter the facility name, state license number, and Medi-Cal provider number. Ensure all fields are completed accurately.
Proceed to Section A—Request for Information. Answer questions regarding financial statements and patient trust accounts 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 data on licensed beds, client days, admissions, and discharges as required.
Fill out Sections D through J as applicable, ensuring that all financial information is reported accurately according to the guidelines provided in the instructions.
Once all sections are completed, review your entries for accuracy before saving or exporting your filled form for submission.

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Versions	Form popularity	Fillable & printable
2013	4.8 Satisfied (141 Votes)
2011	4 Satisfied (53 Votes)

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What is a DHCS 1801 form?

DHCS 1801 (MH 302): Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment.

What are certified eligibles for DHCS?

Certified eligibles are those beneficiaries deemed qualified for Medi-Cal by a valid eligibility determination, and who have enrolled into the program. This classification excludes beneficiaries who have not met a monthly share-of-cost obligation.