DHCS 6207 Form – Fill Out the Medi-Cal Disclosure Statement Online

DHCS 6207 Medi-Cal Disclosure Statement – Form Details

The DHCS 6207, officially called the Medi-Cal Disclosure Statement, is required by the California Department of Health Care Services (DHCS) for all providers seeking enrollment, re-enrollment, or certification in the Medi-Cal program. Both new applicants and currently enrolled providers must submit this form as part of their application package. The official form is published by DHCS and available through the California DHCS forms library.

Who Must Complete DHCS 6207

Any individual or organization applying to participate in Medi-Cal as a provider must complete this disclosure form. This includes physicians, hospitals, clinics, long-term care facilities, pharmacies, and all other Medi-Cal provider types. Individuals or entities with ownership or management interests in a provider organization must also be identified and disclosed on the form.

Required Information and Disclosures

The form requires comprehensive disclosure of your business operations. You must report ownership interests and percentages, managing control information, business addresses, financial dealings related to Medi-Cal services, and any subcontractor relationships. All information must be accurate and complete at the time of submission to avoid processing delays or denial.

Consequences of Non-Compliance

Failure to provide complete and accurate information on DHCS 6207 can result in denial of enrollment, deactivation of existing provider addresses, and a mandatory three-year bar on reapplication. In certain circumstances, the form must be notarized, except for applicants licensed under specific sections of the Business and Professions Code.

The DHCS 6207 form reflects California's commitment to transparency and integrity in the Medi-Cal program, in alignment with federal Medicaid regulations and California state law. Providers must keep their disclosure information current throughout their participation in the program.