Form DHCS100186 "Drug Medi-Cal (Dmc) Claim Submission Certification - County Contracted Provider" - California

What Is Form DHCS100186?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on June 1, 2014;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS100186 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS100186 "Drug Medi-Cal (Dmc) Claim Submission Certification - County Contracted Provider" - California

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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
DRUG MEDI-CAL (DMC) CLAIM SUBMISSION CERTIFICATION - COUNTY CONTRACTED PROVIDER
County Name:____________________________________
FOR COUNTY USE ONLY:
Provider Name
(Legal Entity):________________________
Receipt Date:
____________________________________________
DMC Number(s):
__________________________________
EDI File Name:
___________________________________________
Service Facility Location NPI(s):
______________________
EDI File Submission Date:
_________________________________
DMC Submission Identifier:
__________________________
COUNTY CONTRACTED PROVIDER CERTIFICATION
As required by 42 CFR Part 455.18, this is to certify that the claim file information submitted by the provider in the DMC submission identified above is true, accurate
and complete. I understand that payment of this claim file will be from Federal, State, and/or County Realignment funds, and that any falsification, or concealment of
material facts, may be prosecuted under Federal and/or State laws.
I hereby agree to keep such records as are necessary to disclose fully the extent of the services provided to individuals under the State’s Title XIX and Title XXI plan
and to furnish information regarding any payments claimed for providing such services as the State Department of Health Care Services or the Department of
Health and Human Services may require. I further agree to accept as payment in full the amount paid by the Medi-Cal program for those claim files submitted for
payment under the program with the exception of authorized deductible, co-insurance, or similar cost sharing charge.
I certify that the services identified in the above identified DMC submission were medically indicated and necessary to the health of the patients and
were personally furnished by me or an employee working for the provider.
Printed Name: AUTHORIZED SERVICE PROVIDER
Signature: AUTHORIZED SERVICE PROVIDER
Phone Number
Date Signed
DHCS 100186 (Revised 6/2014)
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
DRUG MEDI-CAL (DMC) CLAIM SUBMISSION CERTIFICATION - COUNTY CONTRACTED PROVIDER
County Name:____________________________________
FOR COUNTY USE ONLY:
Provider Name
(Legal Entity):________________________
Receipt Date:
____________________________________________
DMC Number(s):
__________________________________
EDI File Name:
___________________________________________
Service Facility Location NPI(s):
______________________
EDI File Submission Date:
_________________________________
DMC Submission Identifier:
__________________________
COUNTY CONTRACTED PROVIDER CERTIFICATION
As required by 42 CFR Part 455.18, this is to certify that the claim file information submitted by the provider in the DMC submission identified above is true, accurate
and complete. I understand that payment of this claim file will be from Federal, State, and/or County Realignment funds, and that any falsification, or concealment of
material facts, may be prosecuted under Federal and/or State laws.
I hereby agree to keep such records as are necessary to disclose fully the extent of the services provided to individuals under the State’s Title XIX and Title XXI plan
and to furnish information regarding any payments claimed for providing such services as the State Department of Health Care Services or the Department of
Health and Human Services may require. I further agree to accept as payment in full the amount paid by the Medi-Cal program for those claim files submitted for
payment under the program with the exception of authorized deductible, co-insurance, or similar cost sharing charge.
I certify that the services identified in the above identified DMC submission were medically indicated and necessary to the health of the patients and
were personally furnished by me or an employee working for the provider.
Printed Name: AUTHORIZED SERVICE PROVIDER
Signature: AUTHORIZED SERVICE PROVIDER
Phone Number
Date Signed
DHCS 100186 (Revised 6/2014)