The California Department of Health Care Services (DHCS) requires the completion of the Medi-Cal Disclosure Statement (DHCS 6207) for all applicants and providers seeking enrollment or certification as Medi-Cal providers. This form is a crucial part of the application package and must be filled out accurately to avoid potential penalties, including denial of enrollment or a three-year reapplication bar. New applicants must be particularly diligent, as any failure to disclose complete and accurate information can lead to significant consequences. Current providers are also held to strict standards; inaccuracies can result in the deactivation of business addresses and reporting to federal agencies. The form comprises several sections, including applicant/provider information, ownership interest, managing control information, and details about subcontractors and significant business transactions. Each section contains specific instructions that must be followed meticulously, such as avoiding the use of staples, correcting errors properly, and ensuring that all required signatures are original and notarized when necessary. Furthermore, the DHCS emphasizes the importance of adhering to the regulations set forth in both federal and state laws, making it essential for applicants and providers to familiarize themselves with the relevant codes before submission. Completing this form accurately not only facilitates compliance but also ensures a smoother enrollment process into the Medi-Cal program.
