Mc 803 2025

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The document is a Medi-Cal Provider Data Form and Disclosure Statement from the California Department of Health Services. It requires healthcare providers to provide detailed information about their legal and facility names, ownership types, tax identification numbers, and any significant beneficial interests held by them or their immediate family in other healthcare businesses. The form emphasizes compliance with regulations regarding financial interests to ensure transparency and prevent conflicts of interest in the Medi-Cal program.

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Click ‘Get Form’ to open the mc 803 in the editor.
Begin by entering the corporate name and legal name as reported to the IRS or Social Security Administration in the designated fields.
Fill in the facility address, including number, street, city, county, state, and ZIP code. Ensure that all contact information is accurate.
Indicate the type of organization by checking the appropriate box (e.g., State government, County government).
List facility owners along with their professional license numbers. If more space is needed, attach a separate sheet.
Complete the disclosure statement regarding significant beneficial interests by listing any interests held by you or your relatives in health care businesses.
Finally, certify that all information provided is true by typing your name, signing, and dating the form.

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