Form DHCS100187 "Drug Medi-Cal (Dmc) Claim Submission Certification - County Operated Provider(S)" - California

What Is Form DHCS100187?

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 DHCS100187 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 DHCS100187 "Drug Medi-Cal (Dmc) Claim Submission Certification - County Operated Provider(S)" - 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 OPERATED PROVIDER(S)
County Name: _____________________________________________
Federal Tax Identification Number:
____________________________
EDI File Name:
_____________________________________________
EDI File Submission Date:
____________________________________
COUNTY OPERATED PROVIDER CERTIFICATION
As required by 42 CFR Part 455.18, this is to certify that the claim file information submitted to the State Department of Health Care Services
for providers operated by the above-name county in the file specified 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 claims 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 Electronic Data Interchange (EDI) file were medically indicated and necessary
to the health of the patients and were personally furnished by me or an employee working for the county.
Printed Name: AUTHORIZED CLAIM SUBMITTER
Signature: AUTHORIZED CLAIM SUBMITTER
Phone Number
Date
DHCS 100187 (Revised 6/2014)
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
DRUG MEDI-CAL (DMC) CLAIM SUBMISSION CERTIFICATION - COUNTY OPERATED PROVIDER(S)
County Name: _____________________________________________
Federal Tax Identification Number:
____________________________
EDI File Name:
_____________________________________________
EDI File Submission Date:
____________________________________
COUNTY OPERATED PROVIDER CERTIFICATION
As required by 42 CFR Part 455.18, this is to certify that the claim file information submitted to the State Department of Health Care Services
for providers operated by the above-name county in the file specified 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 claims 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 Electronic Data Interchange (EDI) file were medically indicated and necessary
to the health of the patients and were personally furnished by me or an employee working for the county.
Printed Name: AUTHORIZED CLAIM SUBMITTER
Signature: AUTHORIZED CLAIM SUBMITTER
Phone Number
Date
DHCS 100187 (Revised 6/2014)