Section 51000.35 - Disclosure Requirements(a) The applicant or provider shall disclose all the information required by 42, Code of Federal Regulations, Sections 455.104, 455.105 and 455.106, on the following forms incorporated by reference herein, using whichever form is applicable, and shall submit the disclosure statement with the application required by Sections 51000.30 and 51000.40: (1) "Medi-Cal Disclosure Statement," DHCS 6207 (Rev. 2/15); or(2) "Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers," DHCS 6216 (Rev. 2/15); or(3) "Drug Medi-Cal Substance Use Disorder Medical Director/Licensed Substance Use Disorder Treatment Professional/Nonphysician Medical Practitioner Application/Agreement/ Disclosure Statement," DHCS 6010 (Rev. 12/14).(b) The disclosure statement shall include all of the following:(1) The name, address, and title of all:(B) Persons with an ownership or control interest in the applicant or provider and the percentage of that ownership or control interest;(C) Persons with an ownership or control interest in any subcontractor in which the applicant or provider has a direct or indirect ownership of 5 percent or more and the percentage of that ownership or control interest; and(D) Board members and officers, if the applicant or provider is a nonprofit entity.(2) Whether any of the persons named in subsection (b), above, is related to another such as spouse, parent, child or sibling.(3) The name and address of any other health care provider in which a managing employee, board member, officer, or a person(s) with an ownership or control interest in the applicant or provider also has an ownership or control interest. This requirement applies to the extent that the applicant or provider can obtain this information by requesting it in writing from the health care provider. The applicant or provider shall: (A) Keep copies of all these requests and the responses to them.(B) Make them available to the Department upon request.(C) Advise the Department when there is no response to a request.(4) The name and address of each person(s) with an ownership or control interest in any subcontractor with whom the applicant or provider has had business transactions involving health care services, goods, supplies or merchandise related to the provision of services to a beneficiary that total more than $25,000 during the 12-month period immediately preceding the date of the application, or immediately preceding the date on the Department's request for such information.(5) Any significant business transactions between the applicant or provider and any wholly owned supplier, or between the applicant or provider and any subcontractor, during the 5-year period ending on the date of the application, or ending on the date of the written request by the Department for such information.(6) The identity of any person(s) who has ownership or control interest in the applicant or provider, or is an agent or managing employee of the applicant or provider, who has within the previous ten years of the date of the application package: (A) Been convicted of any felony or misdemeanor involving fraud or abuse in any government program; or(B) Been found liable in any civil proceeding involving fraud or abuse in any government program; or(C) Entered into a settlement in lieu of conviction involving fraud or abuse in any government program.(c) The applicant or provider shall also state on the applicable application identified in subsection (a):(1) Whether the applicant or provider has ever participated in the Medi-Cal program as a provider and, if applicable, the names under which the applicant or provider participated, and all provider numbers previously assigned to the applicant or provider.(2) Whether the applicant or provider has ever participated in other states' Medicaid programs as a provider and, if applicable, the name of the state(s), the name(s) under which the applicant or provider participated, and the provider number(s).(3) Whether the applicant or provider has ever been suspended from a Medicare or Medicaid program and, if applicable: (A) The provider number(s), including rendering provider number(s) and group provider number(s), assigned to the applicant or provider that was/were suspended.(B) The effective date(s) of the suspension(s).(C) If the applicant or provider was suspended and subsequently reinstated, the date(s) of the reinstatement(s) and a copy of the letter(s) of reinstatement shall be included with the application.(4) Whether the license, certificate, or other approval to provide health care, of the applicant or provider has ever been suspended or revoked, or whether the applicant or provider has otherwise lost that license, certificate, or approval, or has surrendered that license, certificate or approval while a disciplinary hearing on that license, certificate or approval was pending. And, if the applicant is a pharmacy, whether the license of the pharmacist-in-charge has ever been suspended or revoked, or whether the pharmacist-in charge has otherwise lost his/her license, or surrendered his/her license while a disciplinary hearing on his/her license was pending. If applicable, the applicant or provider shall indicate the state(s) in which the action(s) against his/her license occurred, or occurred against the license of the pharmacist-in-charge, and the effective date(s) of the licensing authority's order(s). The applicant or provider shall provide written confirmation from the licensing authority that his/her professional privileges, or those of the pharmacist-in-charge, have been restored.(5) Whether the license, certificate or other approval to provide health care of the applicant or provider has been disciplined by any licensing authority. And, if the applicant or provider is a pharmacy, whether the Board of Pharmacy license of the pharmacist-in-charge has ever been disciplined by any licensing authority. If applicable, the applicant or provider shall indicate what action(s) was/were taken against his/her license, or what action(s) was/were taken against the license of the pharmacist-in-charge, where the action(s) against his/her license was/were taken, or was/were taken against the license of the pharmacist-in-charge, and the effective date(s) of the licensing authority's decision(s).(6) The driver's license number for each person who has a direct or indirect ownership interest totaling 5 percent or more in the applicant or provider. A copy of the driver's license of such persons shall be submitted with the application. If such persons does not have a driver's license, a copy of his/her state-issued identification card shall be submitted.(7) If the applicant intends to sell, or the provider currently sells incontinence medical supplies: (A) A statement of all sources of capital of the applicant or provider.(B) The names and addresses of all manufacturers, suppliers and other providers with whom the applicant or provider has any type of business relationship relative to the provision of services, goods, supplies, or merchandise, to Medi-Cal beneficiaries.(C) The names and addresses of all persons and entities to whom the applicant or provider has extended a line of credit of $5,000 or more.(d) Each applicant or provider shall submit a new disclosure statement to the Department within 35 days of any change to the information previously submitted to the Department on any disclosure statement as required by this Article. When there is a cumulative change of 50 percent or more in the person(s) with an ownership or control interest, since the information provided in the last completed application package that was approved for enrollment, a new application package is required pursuant to Section 51000.30. Changes of less than 50 percent shall be reported pursuant to Section 51000.40.Cal. Code Regs. Tit. 22, § 51000.35
1. New section filed 9-28-99 as an emergency; operative 9-28-99 (Register 99, No. 40). A Certificate of Compliance must be transmitted to OAL by 3-27-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).
2. New section, including amendments, refiled 11-24-99 as an emergency; operative 11-24-99 (Register 99, No. 48). A Certificate of Compliance must be transmitted to OAL by 5-22-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).
3. New section refiled 5-5-2000 as an emergency; operative 5-22-2000 (Register 2000, No. 18). A Certificate of Compliance must be transmitted to OAL by 9-19-2000 or emergency language will be repealed by operation of law on the following day.
4. New section refiled 8-28-2000 as an emergency; operative 9-6-2000 (Register 2000, No. 35). A Certificate of Compliance must be transmitted to OAL by 1-4-2001 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 8-28-2000 order, including amendment of section, transmitted to OAL 12-26-2000 and filed 2-8-2001 (Register 2001, No. 6).
6. Amendment of subsections (a)-(a)(3), (a)(4), (a)(6) and (c) and amendment of NOTE filed 9-29-2004 as an emergency; operative 10-7-2004 (Register 2004, No. 41). A Certificate of Compliance must be transmitted to OAL by 2-4-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL pursuant to Welfare and Institutions Code section 14043.75.
7. Amendment of subsections (a)-(a)(3), (a)(4), (a)(6) and (c) and amendment of NOTE refiled 1-27-2005 as an emergency; operative 2-5-2005 (Register 2005, No. 4). A Certificate of Compliance must be transmitted to OAL by 6-6-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75.
8. Amendment of subsections (a)-(a)(3), (a)(4), (a)(6) and (c) and amendment of NOTE refiled 6-2-2005 as an emergency; operative 6-7-2005 (Register 2005, No. 22). A Certificate of Compliance must be transmitted to OAL by 10-5-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75.
9. Certificate of Compliance as to 6-2-2005 order, including amendment of subsections (a) and (b) and amendment of NOTE, transmitted to OAL 9-29-2005 and filed 11-10-2005 (Register 2005, No. 45).
10. Repealer of subsections (a)-(a)(6)(C), new subsections (a)-(b)(6)(C), subsection relettering, amendment of newly designated subsection (c) and amendment of NOTE filed 8-17-2015 as a deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75; operative 8-17-2015 (Register 2015, No. 34). A Certificate of Compliance must be transmitted to OAL by 2-16-2016 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 8-17-2015 order transmitted to OAL 12-30-2015 and filed 2-11-2016 (Register 2016, No. 7). Note: Authority cited: Section 20, Health and Safety Code; Sections 10725, 14043.75 and 14124.5, Welfare and Institutions Code. Reference: Sections 14043.2,, 14043.26, 14043.27, 14043.36 and 14125.8, Welfare and Institutions Code; 42, U.S.C., Sections 1320 a-3, 1320a-7, 1396a(a)(38), 1396b(i)(2); and 42, Code of Federal Regulations, Part 455.
1. New section filed 9-28-99 as an emergency; operative 9-28-99 (Register 99, No. 40). A Certificate of Compliance must be transmitted to OAL by 3-27-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).
2. New section, including amendments, refiled 11-24-99 as an emergency; operative 11-24-99 (Register 99, No. 48). A Certificate of Compliance must be transmitted to OAL by 5-22-2000 or emergency language will be repealed by operation of law on the following day. Submitted to OAL for printing only pursuant to section 78, AB 1107 (Chapter 146, Statutes of 1999).
3. New section refiled 5-5-2000 as an emergency; operative 5-22-2000 (Register 2000, No. 18). A Certificate of Compliance must be transmitted to OAL by 9-19-2000 or emergency language will be repealed by operation of law on the following day.
4. New section refiled 8-28-2000 as an emergency; operative 9-6-2000 (Register 2000, No. 35). A Certificate of Compliance must be transmitted to OAL by 1-4-2001 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 8-28-2000 order, including amendment of section, transmitted to OAL 12-26-2000 and filed 2-8-2001 (Register 2001, No. 6).
6. Amendment of subsections (a)-(a)(3), (a)(4), (a)(6) and (c) and amendment of Note filed 9-29-2004 as an emergency; operative 10-7-2004 (Register 2004, No. 41). A Certificate of Compliance must be transmitted to OAL by 2-4-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL pursuant to Welfare and Institutions Code section 14043.75.
7. Amendment of subsections (a)-(a)(3), (a)(4), (a)(6) and (c) and amendment of Note refiled 1-27-2005 as an emergency; operative 2-5-2005 (Register 2005, No. 4). A Certificate of Compliance must be transmitted to OAL by 6-6-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75.
8. Amendment of subsections (a)-(a)(3), (a)(4), (a)(6) and (c) and amendment of Note refiled 6-2-2005 as an emergency; operative 6-7-2005 (Register 2005, No. 22). A Certificate of Compliance must be transmitted to OAL by 10-5-2005 or emergency language will be repealed by operation of law on the following day. Deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75.
9. Certificate of Compliance as to 6-2-2005 order, including amendment of subsections (a) and (b) and amendment of Note, transmitted to OAL 9-29-2005 and filed 11-10-2005 (Register 2005, No. 45).
10. Repealer of subsections (a)-(a)(6)(C), new subsections (a)-(b)(6)(C), subsection relettering, amendment of newly designated subsection (c) and amendment of Note filed 8-17-2015 as a deemed emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14043.75; operative 8-17-2015 (Register 2015, No. 34). A Certificate of Compliance must be transmitted to OAL by 2-16-2016 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 8-17-2015 order transmitted to OAL 12-30-2015 and filed 2-11-2016 (Register 2016, No. 7).