Form DHCS5074 "6-month Dui Program Quarterly Licensing and Participant Enrollment Report" - California

What Is Form DHCS5074?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2016;
  • 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 DHCS5074 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 DHCS5074 "6-month Dui Program Quarterly Licensing and Participant Enrollment Report" - California

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State of California — Health and Human Services Agency
Department of Health Care
Services
Substance Use Disorder Compliance
Division
6-MONTH DUI PROGRAM
QUARTERL Y LICENSING AN D PARTICIPANT ENROLLMENT REPORT
INSTRUCTIONS: This form is to be used for computing quarterly licensing fees due and reporting enrollment and
participant data for the respective DUI program. See reverse for completing and mailing instructions.
PART 1 - PROVIDER INFORMATION
DHCS License Number
1. Program Name (as shown on DHCS license)
2.
Street Address (
Check if new address):
3.
City:
County:
Zip Code:
4.
Telephone (
Check if new number)
Contact Person:
PART 2 - LICENSE FEE COMPUTATION
Fiscal Year _______________
5.
Check quarter for which you are reporting.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
(July 1- Sept 30)
(Oct 1 – Dec 31)
(Jan 1 – Mar 31)
(Apr 1 – June 30)
6. Enter months being reported
7. Number of new participants enrolled
Month 1
Month 2
Month 3
8. TOTAL number of new participants enrolled
9. TOTAL Licensing fee due (multiply line 8 by $10.00)
$
PART 3 - STATISTICAL INFORMATION
10. Quarterly total terminations for noncompliance
11. Quarterly number of reinstatements by court
12. Quarterly number of transfers from other programs
13. Quarterly number of transfers to other programs
14. Quarterly number of completion certificates issued
15. Quarterly number of active participants paying $5/month
16. Amount paid to County
$
PART 4 – CERTIFICATION
I certify that the information in this report is accurate. I understand that the information in this report is subject to audit by the
Department of Health Care Services.
17. SIGNATURE OF PROGRAM DIRECTOR OR DESIGNEE
DATE
DHCS 5074 (01/16)
State of California — Health and Human Services Agency
Department of Health Care
Services
Substance Use Disorder Compliance
Division
6-MONTH DUI PROGRAM
QUARTERL Y LICENSING AN D PARTICIPANT ENROLLMENT REPORT
INSTRUCTIONS: This form is to be used for computing quarterly licensing fees due and reporting enrollment and
participant data for the respective DUI program. See reverse for completing and mailing instructions.
PART 1 - PROVIDER INFORMATION
DHCS License Number
1. Program Name (as shown on DHCS license)
2.
Street Address (
Check if new address):
3.
City:
County:
Zip Code:
4.
Telephone (
Check if new number)
Contact Person:
PART 2 - LICENSE FEE COMPUTATION
Fiscal Year _______________
5.
Check quarter for which you are reporting.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
(July 1- Sept 30)
(Oct 1 – Dec 31)
(Jan 1 – Mar 31)
(Apr 1 – June 30)
6. Enter months being reported
7. Number of new participants enrolled
Month 1
Month 2
Month 3
8. TOTAL number of new participants enrolled
9. TOTAL Licensing fee due (multiply line 8 by $10.00)
$
PART 3 - STATISTICAL INFORMATION
10. Quarterly total terminations for noncompliance
11. Quarterly number of reinstatements by court
12. Quarterly number of transfers from other programs
13. Quarterly number of transfers to other programs
14. Quarterly number of completion certificates issued
15. Quarterly number of active participants paying $5/month
16. Amount paid to County
$
PART 4 – CERTIFICATION
I certify that the information in this report is accurate. I understand that the information in this report is subject to audit by the
Department of Health Care Services.
17. SIGNATURE OF PROGRAM DIRECTOR OR DESIGNEE
DATE
DHCS 5074 (01/16)
State of California — Health and Human Services Agency
Department of Health Care Services
Substance Use Disorder Compliance Division
6-MONTH DUI PROGRAM
INSTRUCTIONS FOR COMPLETING
QUARTERLY LICENSING FEE AND PARTICIPANT ENROLLMENT REPORT
PART 1 - PROVIDER INFORMATION

Enter Program name as shown on license and number that appears on license issued by DHCS.

Enter street address at which program is located.

Enter city, county and zip code.
Enter name of person to be contacted regarding information reported and their phone number.
.
PART 2 - LICENSE FEE COMPUTATION

Check the appropriate quarter and enter the fiscal year for which information is being reported. DO NOT check
more than one quarter or enter report data for more than one quarter on each form.

Enter the name of the month which you are reporting (e.g., January, February, etc.).

Enter the total number of new participants enrolled during the month.

$GG the total numberRI participants enrolled during the quarter.

Multiply total enrollments shown on line by $10.00 and enter the dollar amount. This is the amount due
PART 3 -STATISTICAL INFORMATION
0 Enter the quarterly total number of participants dismissed from the program for noncompliance.
1 Enter the quarterly total number of participants reinstated by the court.
2 Enter the quarterly total number of completed transfers from another DUI program.
3 Enter the quarterly total number of completed transfers to another DUI program.
4 Enter the quarterly total number of completion certificates ISSUED.
5 Enter the quarterly total number of active* participants paying no more than $5.00 per month. Participants who
qualify to pay the $5.00 per month fee for 1, 2, or 3 months during the quarter count as one participant.
6 Enter the total dollar amount paid to the County for the quarter.
* Active participants include participants who have been dismissed, transferred out, or completed during the
quarter.
PART 4 – CERTIFICATION
17. Report is to be signed and dated by the Program Director or designee.
Payment is due within 30 days after the close of the quarter. Mail this form with a check payable to the
“Department of Health Care Services” for the amount due to:
Department of Health Care Services
Driving-Under-the-Influence Section
P.O. Box 997413, MS 2602
Sacramento, California 95899-7413
Questions regarding completion of this form may be directed to DHCS’s DUI Program at (916) 322-2964.
DHCS 5074 (01/16)
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