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Denti-Cal Application Package DHCS 5300 Overview
December 19, 2016
Alani Jackson Chief, Medi-Cal Dental Services Division CA Department of Health Care Services
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Welcome to DHCS 5300 This webinar will elucidate the Denti-Cal provider community on the newly created DHCS 5300 form, a streamlined Denti-Cal specific enrollment application. • The DHCS 5300 stems, in part, from the Department’s commitment to
making significant improvements to the Denti-Cal program, as well as the voiced feedback and considerations of stakeholders in the program.
• Each page along with the features of the form shall be addressed and discussed upon individually and in relation to corresponding page(s) from the existing Medi-Cal enrollment package.
• All pages of the DHCS 5300 form are presented on the left-hand side of the slides, while the cross-referenced DHCS 6207, DHCS 6208, DHCS 6203, & DHCS 6204 forms are represented on the right-hand side.
2/23/2017 2
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Dear Applicant
Thank ;ou for ;our recent inquiry regarding participation in the Medi-Cat Dental Program (Denti-Cal). Please complete the enclosed Denti-Cal provider enrollment application package and return ~ to:
Medi-Cal Dental Program, Provider Enrollment P.O. Box 15609 Sacramento, CA 95852-0609
Please read all the instructions included in the app! cation package carefully and complete each item requested. Incomplete application packages will be returned. It is ;our responsibiity to report to the Denti-Cal Program any modifications to infom,alion previously submitted within 35 days from the date of the change. Most changes, such as a change of o"'1E!rship that is less than 50 percent, may be reported on a Medi·Ga/ SUpp/emental Changes (DHCS 6209)fonn. However, you must complete a new application package if you are reporting a change of ownership of 50 percent or more, or one of the olher changes identified in Galifornia COdeof Regulations, (CCR), Title 22, Section 51000.30, subsections (a) though(b).
PLEASE NOTE: All providers must be enrolled m the Denu.Cal program pnor to rendering services to a Medi-Cal beneficiary. Group providers must continue to confirm the enrollment of all rendering providers prior to allowing the rendering providers to issue services to Medi.Cal beneficiaries. Denti..Cal program will not pay for services, if the rendering provider is not enrolled.
Applicants and providers are required to submit their National Provider Identifier (NPI) with each Oenti-Cal provider application package. A copy of the CMS/National Plan and Provider Enumeration System (NPPES) confirmation document for each NPI ~sted ll the application package must also be included. Current Oenti-Cal providers are required to submit both the NPI and any Denti-Cal provider numbers issued previously on any application forms submitted to the Denli-Cal Program.
If you are planning to sell your busrless or buy an existing busrless, you may find it helpful to refer to the Denfi..Cal Provider Application Forms page at WWW denti-cal ca ggy. The Provider Application Forms page contains information about enrollment options available to you whenever there is a sale oc purchase of a Denti-Cal enrolled provider or business, inch.Jding the option to submo a Sllccessor Liability with Joint and Several Ua/JJ/ily Agreement (DHCS 6217).
Foc more information about enrollment forms and the regulatory reQulrements for participation in the Denli-Cal Program, please review the Provider Handbook, section 3 on the Denti-Calweb srte l sted above or if ;ou have any questons, contact the Telephone Service center at H!Oo-423-0507.
Sincerely,
Denti-Cal GalKomia Medi-Gal Dental Program Provider Enrollment
Enclosures
P.O. Box 15609 • Sacramento, CA 95852-0609 • (800) 423-0507 • (916) 853-7373
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DHCS 5300 Page A-1
• Applicants/providers must read this page carefully, as it directs them to the appropriate form(s) to fill for their enrollment purposes.
• The majority of page A-1 of DHCS 5300 form mirrors the page A-1 of DHCS 6203 & DHCS 6204 forms. The exception lies in the critical paragraph—that has been boxed with a red line, where applicants/providers are informed of the appropriate forms to complete for enrollment.
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GENERAL UISTRUCTIONS FOR CO MPLETING THE DENTI-CAL PROVIDER APPLICATION
This foon is the application for enrollment or contiroed enrolment as a provider rl the Demi-Cal program. Applicants and prtN'iders m.Jst also pn:Mde 3dditiorol infonn.n,on and docu'nMu.tion. Appic.lnts and pn:MMl"'S m1y be suqec::t to an on-site inspection and to unannounced visits prior to enrollment a app,ova.l for con1iooed enrollment in the program. Adlitiona.l infamJ.:ion can be found on 1he ~nti-Cal Web site {www.Den:i-cal.ca.gov) by cfdng the -Provider" ink.
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~\lt>!'rlfflt.Ot<erYke~ plQ~dlWN! er ll\e ~ FrogeJ,n.
5 "futt,adtnss~ is the address 10 vmic:h p,Jyment win be m.lil-ed. The p.Jy-10 3dck'ess should irdJcle, as applicable, the post office bo1C 11.Jmber, street number and name, roomorsute number or letter, city, state. and nne-<ligitZIPcode.
6. "Previous business. address' is !he address Vlhen. the applicant or pn:Mder WJs previousJy enrolled. If the appicant or provider is. not
submitti,g an appication for a challJe cl location, enter NIA.
7. En-..er the T.»p.l')'erldentifica'iion Nt.m:ief(TIN) issued by the IRS under the name of the provider entity; or enter social sa:uitynt.m>el' (seePrivacy~onpage 15i
8 Enter any k>cal business ~cense orpemit 11.Jfl"befs for any city and1or oou,tywhere )OJ conduct 'PS business. If this. does not .Jppty 10 you mark NIA and provide an explanation.
9. Enterthegendefoftheprovidef.
10. Enter the irtfoona".ion fcr}'Q.JrGeneral L.iabiity lnsuance Poicy. This pdicy covef> the caitents of the ~ and is sep.rate fromycu Professional Liability Policy.
11. Enter the irmma1ion for )'CU' Pttrfessional Liability (Mllpractice) lrw.rance Policy.
12. Ched:theboxforyixrWorker!.~tion Insurance Poicy. lf}'Q.Jdonothave1nspolicy markN/Aandexpl.iinwhy.
13. List the name, Tw,e 1 tFl.dental la!nserurber, speciafy, .n:I entiladcressfa'all renderingproviders intheprovidergroup. Attach additiorul sheets. if neoessay. Rendering providffl no1 already rurreflcty E'Mlled as Denii-C.ll prow:len, who are erirc&lg to render services in the provider group rwst use the 1.\edi-Cal Rerxfai~ Provider A.ppi,c.Jlmt'l)sure Statemert/Agreeme,t for PhysiciarvAJied/Dental Provide~· (DHCS 6216) rt addition 10 being listed in this qustion.
14-18. RE"ead and answerlheque,siions..
RE"e.ld and retl.l'TI the Terms and Conditions on pagesQ-15.
1Q-21. Entertheinforrrution re(!lJe,sted onl),38e 1510n::ludeanorigin.llsign.mre, in ink, olthe.ipplicant!pmvidef.
l:H:55300(rev. 11/16)
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DHCS 5300 Page 2
DHCS 6203 This page is the instruction page of the DHCS 5300, where definitions for the required fields are provided to the applicant/provider. This page combines and abridges the instructional pages of the DHCS 6203 & DHCS 6204 forms (4 pages) into a dental specific instructional pages.
DHCS 6204
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Checklist of items to supplement the a~icafion foon(s) :
:I National Provider Identifier (NPI) verification (CMS/NPPES verification) Type 1 and 2 asappl cable .J IRS Tax Identification Number verification prei)linted by the IRS (rf using a TIN to report earnings) :::i FormW-9 (if using a Social Security Number to report earnings) j StampedlendOJSed copy of Articles of Incorporation (if errol ing as a corporation) .J StampedlendOfSed copy of Complete Statement of Information to include all officefS/directors (if erY"olling as a
corporation) .::J Fictitious Name Permit fran the Dental Board of California for this location (rf you use a name aher than your legal given
name« legal entity name)
:::i Additiooal Office Permit from the Dental Board of California [If you av.Tl or have O'M"lefShip in more than one dental office) :::l Busiless License/Tax Certificate J Certificate of GeneraJ Liability lnsLrnnce for the buslleSS address
Certificate of Professional Liability (malpractice) Insurance :::i Proof of Worke(s Compensation Insurance for the business address
Department of Health Care SeM ces Permit (if you are enrolling as a clinic) :::l Letter appointing a dental director [If you are enrolling as a clinic)
J Bil of Sale flf you have bought or sold the office in v.flich you are errolUng) Successor Liability Agreement (notary is required for this form v.tien used for sale of practice, only when applicable)
:::i Fun lease agreement including any sub.lease agreements and/or modifications (if )'OU lease ~ buikfinglspace)
:::i Driver's license or state-issued identification card of indimual signing the awfjcation .J Dental license .J DEA certificate (if appl icable) .J Orthodontia provider certification (form DC015) (If enrolling as an orthodontist) .J Any other certificates pertaining to your practice of dentistry (example: specialty, general anesthesia) :::i Management agreement (If someone other than your office staff manages/runs your practice) :::i Complete ~ i-Cal Rendering Proroer Application/Disclosure Statement/Agreement for Physician/Allied Provider.I.•
(DHCS 6216) for each rendering provider being added to the provider group if the rendering provider is not currently enrolled as a Denti•cal Provider or a currently enrolled provider is due for revalidation.
DHCS5300 (rE-t. 11/16)
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DHCS 5300 Page 3
DHCS 6203
DHCS 6204
This page serves as the reference checklist for applicants/providers. The applicant/provider should refer to this page before submitting their DHCS 5300 form. The checklist possesses a list of supplemental documents the Department may require of the applicants/providers in order to enroll them into the Denti-Cal program.
2/23/2017 5
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DENTI-CAL PROVI DER APPL ICATION
i:~~~~·············································~ ~---------~ ■ Read aH instructions be fore complet i ng lhe application. : FOR STATE USE ONLY ■ Type or-prinlclearty. in ink. •
: ~o~~~v~~Y c;;:::::·. ':!:::,li~;!~\,1:r:~ ~~!';i~~ ~f~~~~~~~~~~;=~)- : ■ Vu.it the Den ti-Cal Web&;fe for helpful tool.i; to aid in completing th is pack.age. :
~ ~!t~.!'n "c~.: ~'\:d•f~~ = : r:t•.aff : ■ ec"..~1: :J'a~h•,:1>~~ I:,~ ■■■■■■■■■■■■■■■■■• l.:d'~a~ !!>?tri'~~~-(~:nu if •••••••••••• : ~ rovider Enrollment ■ ~ -0 , Boi.: 15609 Sacramento, • .;A Q5852-060Q :
~(fti,1~~~·-························ ..................................................... NPI type 1 ( lndividual/Soiepropfie lDr): ______ a
NPI type 2 (Corporation/Partne-rship/Governmentenliy/Nonprofi t/Subpart): ______ :
~~MM"l\!lll!!P• ~ •••••••••••••••••••••••••••••••••••••••••••••••••• ~ New provider ::i Change of buS.-.ess ad!h.55 aJ Additional bvsne5s address Ci New Taxpayer lO ntn1bet" I[] Facility.Based ProYider !, 'Change ol ownersll ip (per T itle 22. CCR. Section 51000.6 ) ~ 'Cumulatiue change of 50 peroent o r mOlli! WI persoo(s ) with CMDl!ml~or ■ ccntrol in11erest(per Tit1e-22.CCR.Section 51000.15) aJ 'Saleclassets50peroentormore. pes-lille22, CCR, Section 51000.30)
~or~:,:u:a~= ~ ;!d=:e:~-=~~~-,-,..~,...- .~ ... ~-,
I intend to use my current pn:wider number to bill for seNices delivered at t:his locaoon while this application n!-quest is pendng. I understand lhat I M l be on pvvisiooal pn:wider s tatus during this &ne. ixr.;u.ant to TIile 22. CCR. Section 51000.5 1
*AEKRYidfr i9Cff1Dent max not l?t 11:ans!trrerf gr us le nest to anetbfc Howen,, an applic.a.nt may be joined to the provider ~ reement by strict compliance with the p,ov+sions o f Title 22. CCR. S@Ction 51000.32 entitled MRequi:rements for Succe;s• Li.d>i1ity with Joint & Sev-eQILiability. -
■ requested by the Oepazvnent 10 apply for continued enn:A-nent in the
.. ■M~-~a!p■rr:'!r: -:-:it.a:::-:.~,;:~:'::!. :1~ ·!5J ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Type- of entity (check one)
□ Soleproprie-tor □ Corporation:
Corporate number: _ ____ _
State inccrpcrated,_· ------
::J P~ hip (attiJCh legi:,le copy of:.greement) ::I Limited liabiliy company (LLC):
LLC ntn1ber: ______ _ Stateregis~dffiled: ____ _
Govefffllenternity Nonprofit corporation Type of nonprofit ________ _ Othoc ___________ _
4g. Olidoie be!IOW. tl ll:lm\albnonpes.a,i1-wffl'lan o"Mll!f5NlporCClnlnll lnte!ftt lnany~r - ar.del'lned ln callrDmlaC00eorftegi.1-at1cn1,. Tltle-22.sectlOl'1S11J00.24- ln
'6flld'I U'lll! ~ t,pro,,lderria& aorect « t11Sreet~p or spen:en1«more. rr non•chKI: ,_.: D {Ntai:tlaCl'2DOl'lal5tleE'I rne::el-5¥'f. btiefl!daC1otron.a1quKIIOfl 49)
cm oewme 00Mamroa1Me::1« Muer rnemwm¥ae:mM nr--arnrm, nX1e 2rrwurann E "ill §f:SJOOi'iJ9P9 i\'iCSYi'i>
mes 53D0 (rev. 11116)
DHCS 5300 Page 4
1
2 3
4
The red box contains content from the DHCS 6203 & DHCS 6204 forms with four significant changes. 1) There is added information about the
web aid tools for providers to employ in completing this package.
2) The Medi-Cal return address has been removed. Hence, applicants/providers are expected to return the completed package to the available Denti-Cal address.
3) There is a required field for the types of NPI the applicant/provider may possess and the business type.
4) The repetitive request for the effective date of the ownership change has been deleted.
2/23/2017 6
~HCS
DENTI-CAL PROVIDER APPLICATION
Important: Read aH instructions before completing lhe application. Type o,- print c learly, in ink. tf you must m ake correctiClf'IS, please line throug h. date. and in itial in ink (do not use whiteout). Do n ot leave any q1Je&tion&, boxe&, line&, e tc. blank. Ent« WA if not app ricable to you. Vi.sit the Denti-C.il Webs;te for helpfu l tool.s to aid in completing this package
Return comple-ted forms a.nd aJI applicable attachments to:
State incorpora
FOR STATE USE OHLY
4g:.Ol~be!'<M. tlltlm\olllell'lonPH5M, Wl!l'l an OM'leAl'1P or controlll'lteA!Cil ln;rl'f~f - .-.~ll calllt:ll'TllaCOdeOIRegl..lall0N,, Tltle 22.sedlOn S1COll24- ln
'6tlld!U\e iipplleantlprovlclerBa& adfid:Df tlcllKllowrtef5hlp CCSperoenlormDll!. tf non•cllaca rw.: D (.-ltmdiiilddtliona:5hee1 l n E!01!56al)'. [email protected] qill!6tlon4g)
:::: I=:::: I= I:=: II YMi: df'fdllhfOOOOiJltu'.Wal fitJefl clPiiPff memszre:ilfr10Je11nGa(CPcr:acooe9TBf91CIUJKJi JI::'""P S&l905100QiWS1¥5)
OHCS 5300 (rev. 11116)
,.._ ----- ---·-------,-.-.~..o-,,,.-.r,:_......... - ~ ...... B-----4--••- •---.--~--A::,.-IIA r-.---- ·;,;t.M.o,.,.,..,.....__,, _ •• _.._,_,_-, ""'-
i·-ii.-=--- -=-~ = --!I ...... ...... --.
•--- -- c - Cl '-• '"' _ .. _________ ,. ___ \ _ ,..__ _,...., ____ ., .. ___ .,. ___ _ ,,..., _____ u .... ;t.-•W . ·----------,~..,_ .. ___ _ -------5'-:--=--,_ D- -D-- , . ._.,_ ~~~~=='.S"-~1-=:1~-=
- ·------11El»GALffll(Wm,UIGltOlJPAPf'l.lC,t.TION ---- I
□ ~ .. ....,_._ ., ... _.,_ =- =--=--
.,_,,_ ..... ___ _ .,_,,_ 4_.., __ _ _ _ ....... --- ..
--------~.,.+4_:=:-.,..~~~~,- I h--••-••---•---=-~=----•~--
I :::~:::-..::=:;;..3:~;-:-=~-:s::.~_:_: =-;,~G";·=;f:::::::.~~.:.~~::s =:.::::.c:!::"C::---:="::'i'"'llttl;.ll---•-tor-al ___ _
lG ___ ..__......,. _ _ .. _., __ .. ___ ~,-t ai
q~~~i::::F.-~-=;=~~~~
~d...,kfw4-l ~-- .. -~--,-11-- n ........ ...._.-.. 111.e. --:::.:._-:.--- :::.----- :::"'-
··----·--- ... ---·---- -., ., :..:;-:-~==-==~=
--r 2 :~-r - 1· . ==-- __ _I ... :·=-=--·=·· ' --·--- -
DHCS 5300 Page 4 (cont)
Questions 1-4, combine the questions relating to the provider’s name and business name present separately in the DHCS 6207, 6208, 6203, & 6204. This is the only section of the DHCS 5300 where providers will need to provide this information. DHCS 5300 also ascribes the term “business name” as a synonym to “fictitious name,” to alleviate the confusion both terms.
2/23/2017 7
~HCS
CENTI-CAL PROVIDER APPLICATION
J U I U
reques.ted by the Oepanment ID apply tor conlinued eodnent in the Medi-Cal p rogram pnuant to Tltle 22. CCR, Section 51000.55.)
Type of eniity (ched: one ) □ Sole proprie1Dr :J PilltneBhip (a ttachlegille-copyafagreement) .:J Corporation: .:J Limited liabil ity comp.any (LLC):
Corporate number: . .. _ ______ LLC nwnber: ______ _ Stateincorporat:..__ ______ Stateregi'Steredlliled: ____ _
.J Government entity
.:J Nonpufiicorporation Typeof~nft ________ _
.:J Other: __________ _
■ ,4e_ L..e'601"act:lres& 4f lft'Mll" ~ n~ r . ( ) . ••!~~:!e •~ . ::i:::C:.:;:,:::n~ "a,~ ::r!,: :.:~ r~!:e;.::~~~~ ~~!o~.~~•~ •s~~ 4~1: :
: lmlctltheappllcant -proY!Mr ha&a dnct artlcll!Clownervilp cf S p,!ltleR ar mon!. lfnonacll&di~: D (Abaal ilOdtklnal 5hee! l neoe'5;I)'. liil181!d D1llon.alqtJKllon 4g(
~ orName ""'"'"'""
,!; ____ ,. ____ __ • ._ __ ,._, _ U N &
II., _________ --•-•~
, ____ u - ..
I:;::...-::.:;==-.-;::..-=:..:-.::-:;_.__-.,;.;.,'".--=.=~
··------ o. ·-----------tt 1••---- -- ------ ---ll~==-= n--e- -·i:::::.-.,--- ---
'f. WllCowmN:'TOIIFOIIMAllOltNCl~«Ml;SS ntAJftAClDK~
t i:..- ·..,.,, ·-------
........ ~ ...... ...._ ..... ,,!'.11.,..0.. . ..... ';J .. •~--·- - i:;: - □ ..........
., .. ---•..,--•-•r-,,r.M r:J "- r,._ ........... .. .,..... ........ _., .. __ - ... - 1:.- .]-
,;.;
- ... - ..... -.. -~,..~,o--... _ !:!,.•·--·--- - c- i:--u-.- u-.... - --·~--•-Wt- •to.1P ClY• ::i...... -.. _.._ ......... _., .. __ ~-= ca.a a-. ca..- 1■-■-1
c,...,.~..,..,...,. ...... _ .. ~-"""'-...,..,.., =---.... Jl'l~_ .. ,.,.,..._....,...,.,,._..,_ ..,._ ___ ., ___ ._.,_ .,. ___ _ ---·--· .. -·-·-----.. ------·-··-· .. -·_.---.... ---.. -----•-I! .. -•-·-·-·-..-,• .. -·-- ..... .__..,__ =~~==-=--==· ------·------...... ,._,...._.~w- o .. •--■----.-.--.. .....,•r-••-•-• -,,___.., ___ _ ['i::C'l----------·- --.. ---.... ·.-...io~-,-.....-w.--,,,--
po ......... --■-~-··--·-------··-.,-·-·· ---------- ~ "- u .. __________ ,-----··-oT- o;..
:-.=.:::-:::====-:=::==-. --·--~---, fiFt::1-.--l,lo...,;;; :'.::--·------_::i:_--•-- -•-•-----•- •---.111--.... --Y---.') c c.- ... , _____ ., __ -
-=-:.---.. ,;x.._,. __________ ..
u,..•-- _.,_ _ u-n-- 1"1--:~===.:=:.=:::=.N~:ff" I- ~-~;:::,,.,,:s::.; .... _
,_.., __ ,_,_..__,__,._.,,_•~ l'Jlf OT- □-, __ ,.. ___ .. .,. _ _. __ _ LI- LI- LI- U- ---
I) =-:-~--::.:...-=~-===-~-=-=..:::=--==-~~ :.":--=-~=~-=::==-~:=:--.;:-..:::..-:=.=-... _____ ...... _ .. __ .,....._~Y ,...Ol
2=.:.:::-:=.=::.~~-:=-....:::::=:-..=::::-~--;:~ :,::-=:--,_....--.,--.---,..-. .. - ...... _._ ... __ o--•--•- _,, __ --1 ... .,.. ------· --'9-===:•--------•----.,,-----'I~,-=•===- ~
1;- ,
DHCS 5300 Page 4 (cont)
1
2
1 2
2 2
Questions 4a-4f represent question G1-4 of DHCS 6207 form. The transcribed sections of the DHCS 6207 and its location in DHCS 5300 is identified with a “1.” Questions 4g-4h are questions from DHCS 6207 that pertain to the subcontractor and significant business questions. The transcribed sections of the DHCS 6207 and its location in DHCS 5300 is identified with a “2.”
2/23/2017 8
~HCS
I"' f or I changl of bualr.11 lldclrNI. ant« loclll:IOfl movfng trom (Sf'lllflll , mart. Nl'A -,c1 cor,tlnua io (IINll:lon 7):
I"" 1~ I Hlne-<lkftZl?CCIOe
7. Talp,l)'l!l"tlenlllka.~OOlunbef(TIN) l5aJed bfttle IRS.'or SSN ISl1e Prop~eDr nat1161ng ai TIN
1 1$. Locall!Ulir1K$ IIC@fl5e/Ta:cpetm1truno@I' 19. G@nd@I'
If you, lhe applicant/prov ider, are a pa rtners hip, co rporation, gove rnmental e ntity, o r nonprofit organization, proceed to question 15
15.
2.
3.
4 .
5.
O R
If von the iJPPlicaot/orovider ilm an 1mincomonued sore-Proncielor Proceed to 011es.Uon 1z OWNERSHIP INTEREST AND/OR MANAGING COtHROL IN FO RMATION (ENTITIE S)
In lhe table below. list all oorporations. un ir1COfPO@ted associations. pa rtneOOips. o r similar entitie.s having 5% or more ( direct or inclife.ct} ownership or control inte~t. or any partnership inte-r-esl. in the applieanc/orovider ide ntified in question 1. Att.ac h a separate question 16 fo r eac h entity listed bek>w. Number of page.s attached: __
Che ck here iflhis sectiofi does not aiDotv to You and oroceed to a uestion 17 D PERCENT(~) Of Tn NPI TYPE2 OWNERSHIP OR Identification
ENTTTY LEGAL BUSINESS NAME CONTROL Numbet fTIN}
DHCS 5300 (re v. 11116)
MEDl.c.ALDl!ICLO!UHl:E STATEMENT
P-z--~~-,QIIIIATIOJII ..s. ~.)I-~ - ..... ,._,._ __ ~
• ---·- · · - --- -.mt~ ... ..... - .. . c..~-J-"1•=-----•- --· .... --.-·-0 ... ..,,.,.-.--.-... ---- ... _ __ ~
£ .....
...
--= .... ---o=-. """"-"-- r. ..... "":::"..-:SF==':::.~~===-===-=--= ~i- -•d-•- ,-, --1 t:.~
~-------
- -... ~ ,. ______ _ , __ _ .. __ ~...5:..----·-· :::::... .. _ .. _.., ____ -
.. ~--=~~~~;;:.:
□ E , ___ .., ___ .. _,. __ _ _________ ,_ ... , ---·-· ------·
__ -::,""-:.::.. -= -----· -------- ..,_ r.·---· -- -----~-____ ..,. --·"- ---.......... -
.,.., _________ _ __ H ___ ..... i, ...
I'
---- ·---.. "' ----------·-··------
0---~:""0VIDEJIAl:Nm:MDff I (l',o A~..,......_ ... ,_ .. __ ~
"---... ~ ...... _ .,.._____ ';;;=====
•11:1:<:VTIQMOl'n.,.~i..t.0J111.1CWl'"lfl'N1!llf..,~~OJlll!IIIO\CM!i.-~i.
e.~r:o::~~~::2ot~~=?l*~*~~: 1J9"-4•1{n). 1TILII U. C:ODII. OIi' PUIRRAL JII.Ol.lL.Afl011 .. RCTION -011•r. ~IUl'II -0 91 .. fflUTIOlfli r:«is, MC:"IICI N 1•-.U.J. &MO TIIU: l'J. C:Al,.-0-1& COOi (Ill JI.GUl,.l,.flDNtl. •-="o,.•• ...... 'll, All A aJNCIIIION '°"' ""'"~TIClf mil OIJNTW~O P-TlC-TION ...._ A "'°"'!Oal llf lNII -""IOl-¢.t.l. ~•~ AOJIU:I ft) e,oa.L'I MfMI .t.u. 0111 "IMII ~ '1:-SAHO C:OMOmQII ... IMl:I \NnM Al.I. 0, Tl-I._ TIMltl bO CONQITIONII INC~ Cllf/Uff &TU.~lffift t11:•T0 . ¥11NtC"4RltMll!l'IGOIOl~Tl!D~NBTJll!rfflil.Jl&C
====c-- -----··----------. -='---------~··------
.:..
____ .. __ ":,; __ ., ,-
DHCS 5300 Page 5
Questions 5-9 of the DHCS 5300 on the left-hand side are the streamlined version of the fields previously required in the four pages on the right-hand side in the DHCS 6207, 6208, 6203, & 6204. Non-dental related fields were eliminated, such as taxonomy and medical license number.
2/23/2017 9
~HCS
s. PaY-«I a~ fnlllltler. ill'ffi. P.O. 8oll:nl.fflber} I°" For -1changt QI bu.I-. adl:!!911._ triter locatlon moving trom {l'non9, m¥k NrA 9'1d i;:ontlnu1t lo queetlon 7) ·
7. ~ lkleflllllca::.on lunber (TlN) l&aJed by!hl! lRS.'Dr SSN rSde Propn~arnolU5lngi1TIN
ap tar'll ~e R'fl l'IOl!il& II . K lta~. ztDlprolll'lll' m.-itenanceQI WO!ler ,CO!rfl'ng:on,~_lfn«;ippt::at:ie. cfiecl HJl.~PfWIOe.iexpl.i.r.onbelow:
pmgramr; Ill.at IU\lenot t>een p.ald al'ICl'IINt .11nangement1. ruve~mll:le to n.ffllltrie ~none, ). SUbrM coptK QI all~ pMalr1i"lg ll0 11Warrangem«r15 1nc:1ue11ng IM!"6
anc:ICOIICICCIBL$eeC.VnrnLaCocleQl~.ttln5 tCCR). nae22, Sec::u,n51000.50(aJ(6).
llnor. <:n.ctl,... 0
If you, the app licant/prov ider, are a partn ership, corporation, governmental entity , or nonprofit org3niza1ion, proceed to question 15
15.
1.
3.
4 .
5.
OR It voI1 the :mnlic.aot(Qrovidec are an ,m inrnmorated sore-nroorieror nroceed to mIesuon1z
OWNERSHIP INTEREST Af.1 0 /0 R MANAGING CONTROL IN FORMATION (ENTITIES}
In the table below, list a ll corpora tions. un incorporated associations, p.1 rtnerships, or similar ~ tities h.aving 5~ or m ore ( direct o.indireci) ownersh ip 01" control interest. or any p.artne~ip in terest. in the- applicant!cirovider ide ntified in question 1. A ttac h a separate question 16 fo r each entity listed be low . Number of pages .lttached: __
Check he-re if th is section does no t .loorv tovou and oroceed to ouestion 17 D PERCENT ('Ji ) OF Tax NPI TYP E 2 OW NERSH IP OR Identification
ENTTTY L EGAL BUSINESS NAME CONTROL NumbK (TINI
DHCS 5300 (re.., , 11116)
--== m;
... -.. --·-----.. -·---- - -·
.. _.., ___________ , ... ...
·- - -· 1-
·----·--·-i-- 1~
I'"
• .._,,,._____ I, . - ·-·- r-·--• 1;- + r-··--- -..... _, - .. --·-
t ' ' _ ____t_-,
mm ' . ----· 1· -
t:™• ---
.. -•---=-- __ ,. .. -
I r---•-"'-•
i=-.., ___ _
I
E~-----.. --_ -. - :== • ~
DHCS 5300 Page 5 (cont) DHCS 6203 DHCS 6204
Questions 10-13 streamline the required information for the general & professional liability, workers compensation, and the rendering provider information from both DHCS 6203 & 6204 respectively. Additionally, fields pertaining to medical treatment e.g., hospital privileges were eliminated.
2/23/2017 10
~HCS
1sute 1N~ZIPoode
7. Taxp,1Jllltlemffica1ontunber(TIN) lilUedbylhe lftS.'a SSN ISci:I! 8. lOCillCU&IIK&ICe'l&e'Tillpemtrantier t . G\ll'IOer Propfle'.orral1161ng i1 TIN
ii ooeilneapjiiicriliaVi!Wiiuri~r.a,;inoeasridbyitiiiii? LJ TK [_fei LJ klA lf~, ;ElaCtli:rr.,at'(tl'IIJl'lfEoll.Jl'IOl!UWOlll<l'$~1'15!ni'a. lnal~, Ch!CIHIA.n:lpn,tlllf;l"IHplZ!al.01'!Cll!kM':
I I I I I I I I
1.t l.lit~lln@fJdetu C11e.I1Gtllffl9D)'appllc.ilrt.~.GKto.wiy:ederal,m:e, a-looJi permMtM.!Ueto ~ . Medcalcl n::ia1~1eoe~~ae toul'l1 ~
~u~na:Deenp,akl arxl'llll\al~llil'IE'Deelllllllto Mll lheOllllg.l~Clll[i ). Sllinitcq,IKlt.ilOOClme!ltiper.alrtngtolhe~lndl.dngtern
I ..... "'""
If you, the applicant/provide r, a re a pa rtnership, corporation, governmental entity, or nonprofit organization, proceed to question 15
15.
3.
,. ,.
OR
If vou the annlicant/nroxider ilte ao uoincomocated :wle-2rondetor nroP:sd to mu:sJioo17 OWNERSHIP ltHER EST AHD/OR MANAGING COHTROL IUFORMATION (EIHITIES )
In the table below. list all ccrporations. uni~ted associations. partn~ips.. or similar entities having 5'16 or more (direct Dr
indirect) owner.;hip or control interest. or .iny partnership interest. in the applicant1orovider identified in question 1. Attach ii
sep.iirate question 16 fo r each entity listed below. Number of pages attached: __
Checil. hefeifthis sectioo does notaoDlvtovouandoroceedtoouHtion 17 D
ENTITY LEGAL BUSINESS NAME
PERCENT ('!lo) OF OWNERSHIP OR
COHTROl
Tu NPI TYPE2 ldenofi~ iion
'"""" (II<)
OHCS531JO (rl:'V . I IIICI)
MEDI-CAL DI.SCLOSUll:E STATEMENT
( r-.--.-.•-~-•..,.._....,..,.,. __ ,,,_,_ L N•A
o...,_,.. •• ~,.....,.., ,...,a,,,_~-u .... ~•-..i ,... L.. N ll,
Gm..;
t ~~---, CY .. c ... t r,t, ---~~-~ .. '--MIi_ ,_,,,..,._...,...._ =-~ .... ..-----... --~...------... -
; ,._..;;;.;....:....; '"' ) ,....__"Akn---M~ □Y• l:J N,, l r~-Nll-<f_._~_.,-
N_'rp,111!~..--,:.,ii
D_.....,,, --!Ill,~~_, o-e::.-::.:....---n=-::,_
n-
I
--r o..... n o,,.
I ,,. __ ..,...,...., ______ _ I
.. •---.. ------•---~.--c-,. ~_,.. _____ ..,.,_..,_ ... _.............., __ . ._, -· ...-a-af'4naM111 , .. _...,katl...,_.,.._.IIIIB_ -' a.d+..l.._ ___ ...., __ ..,'--"H
..,_
.... '
-"-
....
~=---- ---· -
--
-
DHCS 5300 Page 5 (cont)
Although question 14 of DHCS 5300 mirrors question “I” of DHCS 6207, its location is different and is more expedient for the applicant/provider in filling out the form. Question 15 on the other hand simultaneously reduces the filling space as shown in DHCS 6207, III(A), and adds in new columns: Tax Identification Number (TIN) and NPI type 2 information. The inclusion of these fields in this section avoids any unnecessary duplicate ownership information disclosures pertaining to entities.
2/23/2017 11
~HCS
16. OWNERSHIP INTEREST AHO/OR MANAGING cornROL IHFORMATION {ENTITIES)
A. En1itywi1h (Ditffl or lndrect) Ow!ief!>hip lntefeSI. andror Mlllagi'lg Con1rol-ldentn:tion lrronTlafun.
I. Legal bu5ine!t5. n.Ine
, 2. FIIUKlJS.n.ne (l ~Je)
J. Prinary Busi'less A<ltess' (runber, ~ ) (C<y) (Slate) {NiM--dig~ZIP ood@)
• If this ~ is a corporaEoo, attach a ~stof AU. bu!iiness ~onaddres!.es andP. O.Box addre!.Ses o( the corporation..
4. Checl: al lhat apply:
0 5%or moce~ip interes.t □ Managng contro1 □ ""'""' D °""' 1.--------5. E..'fec&e dateof ownenhip ;"'tdconm:,l (ITll'Ndd'y,yy,-.· ___ _
8 . Respond E the following ques tions:
I . W"rthin ren ~ ,m; from rhedare oflhit; sQremenr, has this entity been convictedd a frdony ormisdemeanor involving fraud or abuse n any government program? 0 YesO No lfyes. povidethe dateoftheconvidion{rMVddlyyyy~.----
2. Wnhin IPn yeaf"5 from me dare ofzhit; sure~nt has lhis entity been found liai:.tortraudor
abuse notmg anygowmment ~ i, any civil proceedng?
lf yes, provide the date offnaljudgmert(fflffVdd!yyyy~.----
3. Wifflin renye.irsfromrhedareofthit; surenH!'nt has this entity entered into asenl~tin I~ of convictioo fa fraud or abus.e mohmg any goverrment progam?
lf:,,es. providelhe date oi lheSEctd!ment(nvn/dd/m'Y):. ___ _
0 Yes 0 No
0 Yes Q No
-4. Ooe-s thlseniity curren'lly part~ . or has this entityeYer p.articipated. ua provider in the Denti-Calprogam in this sta:e or in anotherstr.e's Medicaid program? H yes, provide the following in!oonalion:
0 Yes □No
NAM E(S) NPI AHDKJR STATE (LEGAL AND DBAj PROVIDERNUMBER(S)
Q Yl!'!i Q No
If yes, at!adl verification of reiMtalement and proYXie the following infotmation:
CHECK NPIAtn'OR APPUCASLE EFFECTIVE DATE(S)OF DATE(S) Of REINSTATEMENT(S).
PROGRAM PROVIDERNUMBER(S) SUSPENSION AS APPLICABLE
0 Medi-Cal
□ Medicaid
□ Medic.n
□ Medi-Cal □ Medicaid
□ Medic.n
6. l~I the name and address of all he.tth care provide~ . partripating or not participaf ng in t.le<i-Cal. in which this e,tity al'SO h.H an awner..hip Df oontrolintel'l5L lf none, eh~here. 0 ff adcitiM31 !.p.lCE' i!il'le€dedaruch ackitionalruge lbl:let"A6:liiioro.ll cp,mtion 16itemB6J. Number of 03geanached a. Ful legal n.Yne of health care prn'lider (rdude any fictitious buffle.55 names)
b. Adcte!is (nunber. street) (C<y) (State){Nne-digl ZIPcode)
OI-CS5300 (rev. ll/16)
re,-,. .. _
n~ .. --- n..,__ n - ~-=-.,... ':z.:==-- I """;."•=--, _______ ,, ___ ... ___ ,,...,"""" .. --------.--, .... -------~--·~----
I ~=!..:::.=;:a~-----• ·=-&::..-:-.:.-=:::-.... -=..-..:;.:"--·-·-- c,.._ C• . ...,_ .. _,, .. _~-. _______ ... _________ _ _..., .. __ , __ .,,.. _ .. _.,._
DHCS 5300 Page 6
Question 16, is the follow up inquiry on the ownership disclosure for the entities. The only significant change made to this question from its corresponding DHCS 6207, III(B) is the replacement of the “Doing Business Name” field with the “Fictitious name” field.
2/23/2017 12
~HCS
17.
18.
OWN ERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION IIN DIVIDUALSJ
ln the table below. list any indmclual that has 5~ or more (direct or indirect) ownership or controt intef@st: or ,myp.annership intetesl in lhe appicantlpovider identlh!-din question I . In add" on, itUofficen.of the oorporation, diredors, agen~andmanaging employHS dthe appicanli'provider mustbe reported in this section Attach a separ.11te question 18. for e•ch individual listed be-low.
lll'IID.JAI... NAME
2.
3.
4 .
5.
PERCENT {"') OF OW NERSHIP OR
CONTROL
Social S~ urity Number (SSN)
(Requir!d)
OWNERSHIP INTEREST AND/OR MANAGltJG COIJTROL INFORMA TIOtJ (INDIVIDUALS)
NPI TYPE 1
A. klentificafoo Information -fur lndiviluals with Own@!'.;hip orCorurol ln:ere!'.t, ~ - Oi"@cl:ors, Managing Employ@e{s), P~ andlor AgMtS of the PannEf'Ship, Group Association. Corporation. Institution or Entity.
t. F~ l@gll~(ust) (Jr .• Sr., etc.) (Fi~t)
2. Residence~s fniniler. s~l ICitYl
3. Dateofbird, 4. Orivef's license m•1i>er or sta:e-issued idEfltmc:alion number (Attach a cullMf and k-grblecopy.J
5. lstheat:,o,.e. individual~atedtoany nilvi<bal listedin question l7 and.'or 4g? If yes, check the appropriate box and list n311le of indMdual:
(Midde)
(St.n) {~ ne-digit ZIP code)
O Yes O No
□- □ Parent □ Ch" □ s .. .., □ s., □ Olhe< {•-•------
Nameaf individual: _____________ _
6. If the above individual is dirttify as!oOCiated with the ertity idl!fltifiedm question I , what is this individu3"i relationship wilhlhE.applicantlproYide-r? Check all that apply.
0 5% orgreater0Yffler □-.... - □ -• □ Sol! D D~oricfficer, tile: ___________ _ D °""' (sp,cily),
7. If the above individual is dirl'cdyassocia:ed with an enutyidentifie-d in q.E-stion 15, ncicatethe n~I! o(thatenttryinthe space below:
.a. Legal busines.s naml! of l!l11ity as lis1ed in Qlll!stion 15:
b. Whatisthis incfr,,idual's rolew:ththe l!f11ity reported inquestion 15?Ch!!cl:althatapply.
0 5% «tire-a:er OW'lef O PaMl!f" 0 Managi'lg l!ITll)loyee O Aeent
0 Dnaor/ctfic«, till!!· D Other (specify):
B. Respond 10 the folowing(IUl!'Stions:
1. Widlin ren fl!-ilr:& from me dilre of chis .uilrement has th!! above- individual bl!l!fl ccnv\cted of at'lf
felony a- rni§demeana- rwolvirg taud Of abm.e in any~ prt9,Yn?
lf yes,prnvidethl!dateoflheconviction (rmi/dd/yyyy): _____ _
o v~ □ No
OHCS 5300 (re11. 11116)
--
Pr, __ .,._....., ____ _
DHCS 5300 Page 7
Similar to question 15, question 17 simultaneously reduces the filling space as shown in DHCS 6207, IV(A), and adds in new columns: Social Security Number (SSN) and NPI type 1 information, for the same purposes earlier discussed in slide 10.
2/23/2017 13
~HCS
17. OWtJERSHIP INTEREST AND/OR MANAGltlG CONTROL ltlfORMATION (INDIVIDUALS)
In the tlble below. listany S\CIMClial that has 5% or more (director indirect) Ol'l!lership or control interest OJ .iny p.annef'Ship ilteml in the a~defidentifiedin quesicn 1. ln addition. allofficets of the ccrporaoon_ d~. agentsard nuMging ~ olthe appicam'prn'lidefmust be reported in this section. Attach a se-par.ite question 18, for each indiv idual listedb!-low.
IUm.JAL NAME
2.
3.
PERCENT('ltJ OF OW NERSHIP OR
CONTROL
Social S~ urity Number (SSNJ
{Requi!MJ)
18. OWNERSHIP INTEREST AND/OR MAN AGIHG CONTROL IHFORMATIOH (INDIVIDUALS)
NP I TYPE 1
A. klentificaEon lnformation -for lndivi:luats with Ownem!ip orConlrol lrteraSl, Officm, Ducr:cn, Managing EmployH(s), PaMffl and/or Agents of the Pal1J'lership. Gfoup Association. Corporation. lnslffl.ltion or Ent~
1. FUI IEgll nane(Last)(.k .• Sr~ eic.) {First)
2. Residence adaess (rl\llltief. s~ tl
3. Date ofbinh l◄ . Driver's licensentmberorstate-issue,didencificationnumber
(Attach a wtTMt .rd legitJlecopy.1
5. ls theab:Henc['Viclual~.ud10.irr,ndMcalal listE<l i'l quesiicn 17ard'or4g? tf yes, check the appropriate box and list name ofl'ldividual:
(S~){Nne-dig;, ZIP code)
□ Yes □ No
□-• □ ,- □ Child 0 SHng 05"1 0 0ther (e~); _____ _
Nameof individu.JI: _____________ _
6. the .1bove lld1Yidual is direcdy .tSsociated with the erdy identifEdrl questm I, Vlhat is this individual's. relationship with the applicaritr'provider? C~k ~ that apply.
0 5%or~ater 0l'fflel" □ ,-- □-... - □ •• □""' 0 Direc:toddf.cer. tile: __________ _ 0 01h& (s.pecify):
7. lftheabollll!iidlvidual is dirtiedy ass.ocia".edwitlaneitity identified ii cp;stion15, ndical:e- the na-ne-otlhatentfty inlhe- spa,ce-be-low:
a . l@g,llbus.iness nameotentity as lis.li?diiqUH1ion 15:
b. Whatis.this.incflYidual's. role-w:itlthe Mtity~n:iil inque-s.tion 15? Ch@cl:althatapply
0 5'!.orgrealefowner □ Parmer 0 Managi,g~ 0Dftctorfoffioer. lidl? __________ _
B Re~IOlheloloW!ngcpstions·
I. W-nhin lea yt'•n; from the d•te of rt,;, li!.ill'ffl!Mt h.H the abcJve individual beM convicted o( any
felonya~an«iiw!wvfraudoral;ime in .tny~ ~ ?
lf yes.. providethedateoflhecon'liction(mmfdd/Yffl'): ____ _
□ A ....
DHCS5300 (rev. 11116)
I J ,....... ..... ........... __ _ m:, ~- mm ~-.r.~ .......... _ ----·--"·" . ... I ---- -1 --....0 !:at .... _.Ill' __
I ____ .,, __ ., ____ .._. __ _
...,._,,., ___ ...,..,._ • ..., __ , n - r, ,.
.,..,_ ... _w! ___ _.,,.,,, ----'-'----:L ___ ..,, .. _., ___________ _
"'.._..,..._ __ ~ ___ .. .,.. .... ..-..., U 'r'- U llo
,, .... ------~-- -• ___ ., .. _., ... ,_ ..... .,.._ ... __ WIIII
- ~--/1'-tir-•--..-~...,.,..,t r:i ~ .. c::, ,-
f 0. .... N~--#-..... --••-• H-.C:.._,, ... _., .... -.._ .. , u ..... O•
6.-- .. -----·----~ - - =
""--..,.--.-.-.-.-
• _..,.._ ___ o.-- .. ~-~C-0---~-
■ ...... ------- -~-U $,o,,,,_ u~- □~
I lf---• ..... ------•- L-•--•--..,.._,a..a.•••SOllt' n ,.,_.,~__, a -... r -.- ■--,,.. n ~ r-~------,- , m.-i:-,:,r,l ----• :.::..--.. ~--.. ...,-.. .._. _,__.,,......., .... _ • 1..---""-•-•- L-A. ........ --------.. ---·--1. ~---- 1;~ __ ...,.. r .--n-------- n~-----
'I""-___ .,.,._~-------
,_...._...., -=
.,,,. __ ...,..~--..---
. C . ..... =-,=-;:;::::.
• 11 )1)U. tnc :)pplla.,t1pQYIOl:1, ,ve ~ 1ie1111t1ng provide:r :t(lljng 10" !}'OUP. ~tiOs«llOl'IVIII
-
I
DHCS 5300 Page 7 (cont)
Question 18A (1-4) of DHCS 5300 combines all questions previously asked in DHCS 6207 I(J), II(A-E), & IV(B)(1-3) that pertain to sole
proprietorship personal information. Thus eliminating any and all duplicate information requirements.
2/23/2017 14
~HCS
17.
18.
OWHERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (lt~DIVIOUALS)
lnlhetablebebw. ~tanyildivwalthath»5% orrn<n (dirmorindirect) 0¥111eMiporoontrolinterestaanypartnenhipnteres1, il lhe a~pl'O\lidef ide11tifle-d in question I. In addi6on . .ill officers of the CCl'pOl'ation, directors. agentsard managing ~ olthe al)l:icantfpto'lideunvstbereported in this section. Attach a~atequestion 18. iofuch in<liYidual listed below.
NL1T1befof=n<><.a-uched:
PERCENT (%) 0F Social Sreurity NPI TYPE 1 OWNERSHIP OR Number (SSN)
Nf4l.lAL.NAME CONTROL (Require-d)
I.
,. 3.
4
5.
OWtlERSHIP INTEREST AND/OR MANAGING CONTROL IHFORMATIOH (INDIVIDUALS)
A. ldentifx:afon lmoonation -for lndiviluabwithOw!i~orCoorrol lrterest,0!5c:en,Di'ectors,M.tniigingEmployee(s), Partrlef!,and,'orAgents ofthePa11111!Mip, GroupAssoc:i;rion,C.Orporation, lnstivlionorEntity.
(Fil!.t)
2. Res'denoe.xlctess (ni..mber. stre;;tl !City\
3. Da:e-ofbm 4. Driver"s lio@nse nlffl>@f or sta:e~sued idenuficalion numbff (Aitifdl acufTMlandJegibl~.)
5. 1-.theal:o,,e ~ra-iated II i1fff irmwallisted in quesim 17 .:n!/a-4{1? tf)eS,ch.eektheappropriatebox.n:llistnarMofindividual:
(SW) (Nne-<IQ.( ZIPcode)
O Yes O No
□-• □ ,- 0 Chid os .... □ s,, □ Olher (e)JIWI): _____ _
Mameof individual: ____________ _
e. If the aboYeindividuJlis direcrfy~sociatedwilhlhe ertityidemified il queslxln 1. Ylflat i!;this ind iYldual's relationsh~ with the applican~'prowter? Check all lh.1! apply.
0 5%«i,-eaterowner □--~ □- □$,if □-1-1, □ Direc:torfoffic:er. lile:. __________ _
7. lflhe.iboYe indiYidual is direcdyas§()(;Wedwiti.JnemityidentifiedinlJ)e5tion 15, rdcalelhe n.Mleoflhatemity in ltM!~ below:
a. Legalbusinessnaml'ofemityitS listed inques.tion 15:
b. Whalisthis ind!\lidua'srdew:thlheeniity~rti;d in ques,6on 15?Checlalthatapply.
0 5'4 orgrea1£-r(IM)H O P.inner- O ManaQng~ 0 Agert
01mctor!cl6cEr, til1r~--------- O Other (speciry):
I. W"nhin 1M )'t'il1i' lrom rhed1teoffhis-5~twnent. h.»the above individual been cawi<:ted of any
felonyorrnisdemeir101"~taudorabt6eina,ygr,.,enwnert ~ ?
lfyes. pro,.idetheda"..eof lheconviction(mm.'ddfyyyy) ____ _
O res □ No
OHCS5JOO (rev. 1tf18)
,m-= ....; "' -- ....... _ """---r-·-.,.. _________ _
---- :J..,. _ ____ _
, ----·-------.--.·'-•-·--·-- .. -a..•-.., p,-. .-r-- - a __,..~ n..-c--~~~~~~ c-- __ _ .. :--........ - .... --.-·- ·- .. -· ... --· .. -. _________ .._.. . ........ t ______ .,. __ .. - ., ,:i..,:.~--
Cl ..... r--- C ..__ i..~~ c ..... I ______ ,,, ________ ,,, _,,
--------·---· , .... _ .. _ ... _ .....,,,.,._~----~ ----------------------·---... -_.. r,n_,. ___ ....,_~-~----• ____ ... _ ,,, __ ..,.t. ____ ,
-·---.. -..... --,...,--.,.,,,,- - c ... , .... -.. -· .. - ..-.,,,,,,._~----
I .._,..-_ I
I I
DHCS 5300 Page 7 (cont) Questions 18A (5-7) closely mirrors the context provided in DHCS 6207 IV., B(6-8). However, note the checkbox “self” was added for the applicants/providers that this field applies to.
2/23/2017 15
B. Respondtllhe folowing(JIE'Stions.:
1. Wnhin zen _r!an;: from me dare ofrhis sraremem. has the above m"rvidual been convicted ci arr,
felony a msdemearxr ~ iraud or m e in any penmert prog.yn?
ies,prtNidelhedat• of ~econviclion(mmlddl)yyy): ____ _
DHCS 5300 {rew. 11/16)
0 Yes □ No
....................................................................•
l:. - - -- -----~------------- .. -·----·--.----" .. ____ ..,._ )
a. ------ ... ~·-·--------· -----------..--..---,. __ --·-------•-----nv- o ....
-------- ..,_, .... _. _____ . .,.._., __ ... ___ .,. __ ----... --.. .. ______ c-.- c:, ,_
I ·· .:.-~ .. ~ I
. ~--•--- -----.-h ___ ,,,_ __ _ "-----.. ---~, ______ .. _..,._ --------··----·------~ ~--·--~~-~--=·· I « <u.m<oa ><<-,o•
-----------------.. _____ ._ .. ___ ,. ........ _,._,.. ___ ,. __________ ,._ ------------
• +U• 11'>+#1~ ..._.........,.r • .._... ... , c~"• Of"oet>+t"•P-fll '° ~-•""- • .-- ....... • •~l>Y#I,.... -...w.g • ..,.,_...,.,. C Y• • No
lf:,-e-o,.~Mi,)+wo,-,a....._•~..._-(• \ ......_, .... .,<W.......,•_...-f'llll_• .... •...iot-l"---~•,._..• ... -.....-c r r c c;."TNT" O"-Tr /-'il or
LJO£N,-....:.NJ11«Nll1rsl/lC1ll'.»II•>
R _____ ,__..,__ __ ...... '----
j :.-:..-:=:.:.;:;:.:....-;;;..~.:--..:---.'I --- ... -.,...,_ ... __ ...., ___ _ J --- - --------------· ·----·--·
......--, J == ... _________ --~
i-1 -:-- hT+~-= . -- . ___ .. _
T"loa...-111--....rDoall .. II.lo■-----.,--. fi,-<------"'--" a-. t:111'"...,. CIC.. ,. ___ ..,.__ __ .,. ..
~.:;i,.,;,,111 ... _,
'-•---....... ----.. Lapl __ .. _____ _
~ ......... -.., ... _._ .. _ ___, .. U "-..--- IJ~-
c._;:=:;_-----1 ' :::;:--..::::.=:::;.::..~=::.,";
,,..._,._.,._<# ... -~,. , ____ ... _ ,.. __ ___ _,. ___ .. ..., .... _.. ... _.,...,~~ ,_ ... __,, _ .. _____ , _ __ ,...,_,.,_., __ ...... -......... _ _..,..,,,
·~~-...;=::,:.=,:.""" ...... _.. ... ___ _
•-,C T• ■O CC.-o,111,MAnc,M ~
'=--=:::-..= ... :c._;;;:;~~----.;,;... _ _,;;; ·- ----.--: ----. ~~-:l-=-------1:=~-·:..-. -=-=, -------~-: ..., .. - ...... ...,...,.,.,
• try(IY. ~,l~llpn:Mdef". ~ 3J'I~~~ ~~lfCft[l,Jnng~.;adl;llng~.a,gn;qi. pn;w;ttd~
OR
-•--•~rw . .►.••• .. -t ____________ _ $ --------......... -.. .. -.c:111_, ·-----------------· 01'M 0 Ho
-----i'
DHCS 5300 Page 7, 8 and 9
Questions 18B (1-9) are a combination of pages 2,3,8,& 9 of DHCS 6207. The reevaluation of the sole proprietor entity as the same person as the applicant/provider resulted in combining this information requirement into a single required field rather than several fields.
2/23/2017 16
~HCS
8. Has the above individuars license. certifica te . or other <1pproval 110 provide health care eve,- bffn dsciplined by any lice-nsing authofity? □ Yes □No
If yH, include copies of licem,ing authority decision(s), includir,g any term'!i and conditiam; l'or each decision, and provide the fallowing infomiaUOfl:
WHERE ACTION(S)WAS EFFECTIVE DATE(S)Of TAKEN ACTIONjS) TAKEN LtCENSIMG AUTHORrrrSACTlON(S)
g_ List the na.me and address of a ll heat1h ca.re providen. participating Of not participating in Medi.Cal in which the above individual also has an ownership or controlinteresL D If n one, check here.
lf 3ddilionalspaceisneeded a-:t.1Chaddi'5on.llpage(labeled "Additiorul CI.Je56on 18 ltemQJ. NumberofpagE'5 a'1ached:
B. Al:ltnss (runber. sn-et) {City) (State) (Nhe-<fi!,tZIPeode)
EXECUTION OF THIS AGREEMENT BETWEEN AN APPLICANT OR PROVIDER HEREINAFTER JOINTLY REFERRED TO AS "PROVIDER" AND THE DEPARTMENT OF HEAL TH CARE SERVICES HEREINAFTER "DHCS", IS MANDATORY FOR PARTICIPATION OR CONTINUED PARTICIPATION AS A PROVIDER IN THE DENTI-CAL PROGRAM PURSUANT TO 42 UNITED STATES CODE, SECTION 1396a (a) (27), TITLE 42, CODE OF FEDERAL REGULATIONS, SECTION 431.107, WELFARE AND INSTITUTIONS CODE, SECTION 14043.2, AND TITLE 22, CALIFORNIA CODE OF REGULATIONS, SECTION 51000.30(a)(2).
AS A CONDITION FOR PARTICIPATION OR CONTINUED PARTICIPATION AS A PROVIDER IN THE DENTICAL PROGRAM, PROVIDER AGREES TO COMPLY WITH ALL OF THE FOLLOWING TERMS AND CONDITIONS, AND WITH ALL OF THE TERMS AND CONDITIONS INCLUDED ON ANY ATTACHMENT(S) HERETO, WHICH IS/ARE INCORPORATED HEREIN BY REFERENCE:
1. Term and Termination. This Agreement will be effective from the date applicant is enrolled as a provider by DHCS, or, from the date provider is approved for continued enrollment. Provider may terminate this Agreement by providing DHCS with written notice of intent to terminate, which termination shall result n Provider's immediate disenrollment and exclusion (without formal hearing under the Administrative Procedures Act) from further participation in the Medi-Cal program unless and until such time as Provider is re-enrolled by DHCS in the Medi-Cal program. DHCS may immediately termnate this Agreement for cause if Provider is suspendedfexcluded for any of the reasons set forth in Paragraph 26(a) below, which termination will result in Provxler's immediate disenrollment and exclusion (without formal hearing under the Administrative Procedures Act) from further participation in the Medi-Cal program. During any period in which the provider is on provisional provider status or preferred provisional provider status, OHCS may terminate this agreement for any of the grounds stated in Wetfare and Institutions Code Section 14043.27(c).
2. Compliance with Laws and Regulations . Provider agrees to comply with aR applicable provislons of Chapters 7 and 8 of the Wetfare and Institutions Code (commencing with Sections 14000 and 14200), and any applicable rules or regulations promulgated by OHCS pursuant to these Chapters. Provider further agrees that if it violates any of the provisions of Chapters 7 and 6 of the Welfare and Institutions Code, or any other regulations promulgated by OHCS pursuant to these Chapters, it may be subject to all sanctions or other remedies available to DHCS. Provider further agrees to comply with al federal laws and regulations governing and regulating Medicaid providers
3. National Provider Identifier (NPI). Provider agrees not to submit any claims to OHCS usn g an NPl unless that NPI is appropriately registered with the Centers for Medicare and Medicaid Services (CMS) and is in compliance with all NPI requirements established by CMS as of the date the claim is submitted. Provider agrees that submission of an NPI to DHCS as part of an application to use that NPI to obtain payment coostiMes an implied representation thatthe NPI submitted is appropriately registered and n compliance with all CMS requirements at the time of submission. Provider also agrees that any subsequent defect in registration or compliance of the NPI constitutes an •addition or change in the Slformatioo previously submitted" which must be reported to OHCS under tile requirements of California Code of Regulations, title 22, sectioo 51000 .40
4. Forbidden Conduct. Provider agrees that it shall not engage n conduct inimical to the public health , morals , welfare and safety of any Medi-Cal beneficiary, or the fiscal n tegrity of the Medi-Cal program.
01-CS 5300 {rev.I 1/1e)
=:-J..::~=f~"~J'I~~ ~~o:.....~~~~Mi:.~~~ ~~Q.-~~"°1:o~~~•-J;,~ ii;tc:nr;.11, ..... "'
AIAaMIOfflOlil,CllM.IITIC:IIII.DONQIICOIRN.ll!IIPAlfflCft.TIO#AIA""'°""°81:lll"MI! -OM:.AL"IIIOIMAll.l'tll:l"fml!IIACIJll!DIOC~"'"'4N.L 011'1Hl!-.~fl!- NQ ~~-:.:::.~~~:.~"':'~~~(a"AIIT~[~
...... __ ... ____ .,,__ _________ _ -----... --~--,-.-------- -···
DHCS 5300 Page 9 (cont) Question 18B (9) is the beginning of the provider agreement clause. Although the context was not changed the text was relocated for ease of reading and completion.
2/23/2017 17
~HCS
,....,.__~-----------·-·-...... -~- ... -----·--•--"'"--- ----------~----,. ~---.:ioo--•---__ c-___ ..._ ___ • ___ ..,, ___ 01 __
=-::.-:-1•=·::: .. ~-==--------·~""'-.,,.,,.,., ... .,,.__.,.., __ . .._ ........ -~'-~-- .... ---· ........ -.... --. =--=-==~:==--.:==:::.=:-~= =..,.-=-::..~-===-~-:--==--~__., ,,,,,,__ t ..__.._ ___ .. _____ ,,__ _____ .. ...,.._,.
_____ .,_.,._ __ _...,.___.~~),.,__~IIO--------------~ ...... ------Mil"CIP,...-,1'_.,,.._ -~--"""'---•~-lfw ... ,,....~ ........ ....,..--CN:$,-~ ----.. ·-•--...c---.. w_..---~ ~,-, .. . ....- ... -..-.l. ........ •\O'-~•)ID~,..-c.,----n~,_.......,.. --....... ~----....... ~ .. ~~-- ...... ----....... J.. ~-.=c~~---:-=.~~~-=:=--~.::: "'-'-...__, . .,._ _________ ..,_ _ _,_ .. ~ CHCS __ .__,. • ....,. _______ °'\.IIIM•--~-------.. ---~--•~Ot<:s---• -.---.----------~------...-.. -i...-.---• ____ ....._ ________ .,._ _ _.., ___ .. ,t(,!ld ___ ~----...--.~·---..------•--.- -=-~..,._~I--_...,., ---- - II;>~ ;r,;io t;I -
• ...,__ir.....-.._...,._"""'"""'" __ ... _,, .,_ __ "'·---~--.-t...,....,........,,.... _.,., ____ _, • ...,..__._~eH-d•M"f'lc:a,.-, ..,..._
~~:.5:~~g~~°=~~E =====~""·-•-,-s----~--0,------.., ,e. gt11;1,,,,.. _ _...., _____ c; ....... ---.-----~,_.... ------·-·•ot----~---~------·--~--...,,....,--,,,,0.,,:s "'"~ ._,..,.a.-.-.-.c.,.._ .... f".t,O")_ __ ,__, __ ~~c-.-.---~-~::::=:w~~'=' .. "'=::..T--=:.z-==.:: =.=,.~..::..=,=-~~~--~ ,_,,,_ ~ _.k ........,_. ko 11c~-~-------.. --..,,,...._.._._ ..,_,... __ _..... ___ .. _______ __,, ... _,...,.._ --. ... ____ ..,_
ll- =:.-==-~-=--~"'=-...:....-.:=:-.-:..~~~~ ------""'-•---....-.--.-------. ___ _..,_ ... ___________ ... ___ .,. _____ _ --·----.... .......c-------· ......... ---... ~ ______ C. _____ .. ____ .,._.IO~i -___ .,_ ___ _,.._._, _ _,.._,.., ________ __ ---•OHCS "'°""",....,..,._ • ......,_.._~...,..,...,...,~_,..o.164lfl>r"""'dl~ -------~-OHC5 11 _.._,.,. __ _.._~~.-----li!,~---0,,·----~- .
=.===-.:-.~:::=.;.~c-:-~~~~!':::'i~::= NJ Tr,.,------0,--~~·-"""--o. ...... -...--------~-----a..lA----.. --.. --.... e-- >,------·~••1'lO'J-,1.~t--••--=== ---.. ~------·-------~ ,..,., .... .,.__
"'' --- - · - ... ____ ,.. ___ .. ---------.... ------... --___ ,....., __________ _ ____ ..,..,__., ____ _ -· ~~=:::-..:=-==:::..·::=-:2::=....-=:
11, n.-.... ·-~--...-.-----""'-.. --..--•- .. ::: ==~==-~==--~:=...~!" .. -:=: it/ =--~-:a::'7!'.sr-==-~~-:s:.r=:::.=-c--..::::.:.:.:: 1,01 n..----------·-----~1-.... , { I ll 1114'~----------.~<v_..., __ •~____________ ,_ _ _, _ _.. __ ~~-~ ........ --·------------·--------..-... __.,.,--,~ =:,_.:_·=..":..~-----~----111'----
l•~t =--=~~~~~==-~~ ------~-----"--.. "------..---·-----... --,~----------=--... ~ =-=--=---.:=-~~ -=-=-~ =Ooj~ ....... --=---= ==:=i:=:."':;:-'-=·-..., .... ~--~ _ ... _ =--~,.----~----------111 i.-___ __,,.,, ______________ _
==---~---=~i:--==--r!!.-~..::::::"~~-=t:.~-::-:"1-· 0, _.....,__--.(•L-•• .. --•),_ _____ ..
;;;.r~-~~~!Z:-=-a~-====-=~ 1:11 • ...._ .. _ .. _.....,, .. ___ .. _____ .c.. __ _
=--==.=-:-~.:----==:..:---v:--..:...:rin:......~~
...... ~---~,.. _ _..,. ____ __.. ______ _ ==:=.i:_=-,-=-..=,_-:=..,m.!°°~!:!;.,~-==:=: ........... ________ ., ______ ......... ., __
•• ~o,,.o.,__. __ 0!<$ ________ "'-_ ... ____ _ ... _..., ____ .. _...,,..__ .. ______ ,...,__,, -----.. - ..... -. ,,,_..__. ______ Ql_,,,_ --.-. ..... 1,1----
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DHCS 5300 Page 10-15
The outlined pages, 10 through 15, of the DHCS 5300 are a continuation of the agreement
ause, which mirrors the text in clHCS 6208. Therefore, no Dgnificant changes were made. si
2/23/2017 18
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Jegaity, and enforceability of 1he remarilg provisions shal not in any way be affected or inpaired. Either party having knoMedge d such a provision shan promptly infmn the other of the presumed non.applicability of suet, pn:Msion. ShOlJd the non-applicable provision go to the heart of this Agreement, the Agreement shal be terrrinated in a mmner coovnensurate 'Nitti the interests of both parties.
37. Assignability. Provider agrees that it has no property right in or to its status as a Provider in the Medi-Cal progam or in oc to the provider number(s) assigned to it, and that Provider may not assign its provider number for use as a Medi-Cal
41.
provider, provider a
Provider agr provider.
The parties a j urisdiction. 1
I declare u accurate, and
1Q. Pr1'11 11 ameaf
20. l dedan- LJRler1 disclOSl.ftstai ~
81~<,r~J;fl~
'''""''-·----~,,~.,,~----- -·· 21. Contact P!f500's lffiJITniltion
□ Checkhere if )OU..e1he-5al'I!! pEf'SMidenlffied in item IQ -P18VAci SIAIEMENI
{CivilQxleSeaion 1798etseq.)
.... .., □- □-
CHCS5300(rev. 11/HI) 15
..CI.JIRAIWJII--PN.ll ·-·--.. .-.... -.. --,1 ---------·--------------1--•--~-...... --_._• .. ----TMall.<.CII -·-r __ .,._ ___ .. _____ .. __,, ____ i
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DHCS 5300 Page 15 (cont)
The final page of DHCS 5300 combines the signature and/or declaration pages of DHCS 6207 VIII(1-6), DHCS 6208., pg. 8, DHCS (6203., pg. 6, & DHCS 6204., pg. 5 questions 26-33). Please note, that dental applicants/providers are not required to have their package notarized. Accordingly, there is no required field for notarization on DHCS 5300.
2/23/2017 19
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. VII . ,..HARMAC.V ........ LIC ANTS Ot'III ..... OVlDeflla
If-.---.-- .. ----vu -If,..__.,__ ____ _ ---------VHt. .. _ , ___ .., __ ..... __ .. , ____ ~--- ... , ... .. ,.,_ _____________ .... __
~ ~-----•-----af_., .. _i..OCift. r-22. -s,aoo.e . ,._.,.. _____ .. _ __ .., _________ ...._.,Yl, 19-a.-,
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C J-A
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""" - ,_.h.atTTI;;acy appllc.anta/provldor'lli procoocl t o Soctk>n VII .
MEDI-CAL DISCLOSURE STA
i-'HCS
C 1l1h11u, D•r•""''•' of
HealthCareServices
('fll'li ..... CllprC!lfa..._. ........... . _, ... ~Cllldaalf ""'"''~~~-~~ ......... . -• rOAHrWAPPUCANTS:f,_..».._,.c--.a,111_.~ ..-cennlWdffCIOMIOnCll•~N~tllit.
• f(l,rl ~llflffl.'lf.NAOl.lfO AHt.ltANTJ:f_... _,~ ..... ..cl i-...11-...---....:.,111 • .._.--... ,.____,,0I. l l'lll~IA IIQINl!bNPlll: .. llnnNllond_.,~111111 1;,,..,....,..,..,.._.., .... ,.,.... ......... ~ =~~~..i;:,S---l~)-.1 1~
·~•_.,..io.-~~~-~ • A-i .. ~'Mlln~l!IIMflll.CIIIOiadnanS&aliMNd. • Tpoopi,llci-t,MW.
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TABLE OF CON
GOICRALIHSTRUCTIOtlS ________ _,
L APPl.llC:N ITiNK>WJCR •trORMATIO H ---------
11. UllltM:ORll'OR4Tf.0 SOI.E.PnQ,f'RWIJ()R OR II IOMQV.t. AOOIH(;. TO A (;ROUP .,._,_,, ____ ,,, __ ,,_.,_,_, ..... _.,_
0¥.'rO::ks! IIP IH IOU:Sr N IDIOR MAHAGln G COtOROL
0¥irO::fai111P 1t110U:s1 N IDIORMN&AGln GCOtO ROI..
V. SU8COtlTRACTOR IHFO RMATIO H AHO SIGHIFIC.AHT
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, ....,.._ ___ __..... __ .,._.. __ ., _____ ,.._ _ _ __ _ .....,.__..,_...__.., ____ ,..u....o. _____ -i,_ --.~ .... --o1~.ooo-,--_ _._,..,0<..,..._.-..,~.._
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Deleted pages
The following complete pages were removed from the DHCS 5300 package.
2/23/2017 20
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Questions/Comments
2/23/2017 21
