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PROVIDER INFORMATION UPDATE FORM CURRENT CONTRACT INFORMATION ALL FIELDS IN THIS SECTION ARE REQUIRED 1. Type of Group: Ancillary Specialist PCP Hospital Urgent Care FQHC/RHC QFPP/Title X Contracted
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Step 1: Fill in the Applicant Information section with all required details.
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Health centers or clinics seeking initial rate setting for FQHC or RHC services
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The DHCS-3106 FQHC/RHC Initial Rate Setting Application is a form used by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to establish their initial reimbursement rates with the California Department of Health Care Services.
Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) that are seeking to receive reimbursement rates for Medi-Cal services are required to file the DHCS-3106 application.
To fill out the DHCS-3106 application, providers must gather required financial and operational data, complete the necessary sections of the form accurately, and submit it along with the supporting documentation to the California Department of Health Care Services.
The purpose of the DHCS-3106 application is to establish the initial reimbursement rates for FQHCs and RHCs based on their costs and services provided, ensuring they receive appropriate funding for the care they deliver.
The DHCS-3106 application requires reporting financial data, service provision information, and any relevant operational details that affect cost and pricing, including historical cost reports and projected service delivery expenses.
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