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Name: Fillable Online Disclosure to the Department of Healthcare Services Fax Email Print - pdfFiller
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This form is required for applicants and licensed facilities to disclose specified ownership and financial information to the Department of Health Care Services as mandated by California Health and Safety Code. It must be completed and submitted for initial licensure, extension of licensure, or when there is a change in the relationships that must be disclosed.

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How to fill out dhcs 5140

01

Gather necessary personal information, including your full name, date of birth, and address.

02

Locate the section for reporting income and fill in your monthly income details accurately.

03

Provide details regarding your household size, including all individuals living with you.

04

Complete the section that requests information about your medical coverage, including current insurance details.

05

Review the form for any additional required information or documents that must accompany the application.

06

Sign and date the application to certify that the information provided is accurate.

Who needs dhcs 5140?

01

Individuals seeking Medi-Cal benefits.

02

People applying for health coverage in California who meet specific income and household criteria.

03

Those needing to report changes in their income or household to maintain their Medi-Cal eligibility.

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What is dhcs 5140?

DHCS 5140 is a document used by the California Department of Health Care Services for reporting specific healthcare information related to Medi-Cal and other programs.

Who is required to file dhcs 5140?

Organizations and entities that provide Medi-Cal services or receive funding from the California Department of Health Care Services are required to file DHCS 5140.

How to fill out dhcs 5140?

To fill out DHCS 5140, gather the necessary information regarding your organization, the services provided, and other required data, then accurately complete the form as per the guidelines provided by DHCS.

What is the purpose of dhcs 5140?

The purpose of DHCS 5140 is to collect and report data that helps monitor the compliance and effectiveness of Medi-Cal services provided to beneficiaries.

What information must be reported on dhcs 5140?

Information that must be reported on DHCS 5140 includes organizational details, types of services provided, recipient data, and financial information relevant to Medi-Cal programs.

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