Form Dhcs 1735 Medi-Cal Certification And Transmittal
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1___________________
State of California – Health and Human Services Agency
Department of Health Care Services
MEDI-CAL CERTIFICATION AND TRANSMITTAL
PART A
COUNTY INFORMATION
PROVIDER #: ______
NPI#: ________________
COUNTY SUBMITTING FORM: ____________________
PART B
TYPE OF TRANSACTION (Check all that apply)
____________
Activation date:
Medi-Cal Activation
New Provider
Mode/Service Function
____________
Termination date:
All Services
Mode/Service Function
Medi-Cal Termination
Recertification date: ____________
Medi-Cal Recertification
Address Change
Re-certification required. Complete parts A-G.
Effective date:________________
Name Change
Please complete parts C and G only.
Effective date:________________
PART C
PROVIDER INFORMATION
Provider Name:_________________________________________________________________________________________
Address: ______________________________________________ City: _______________________ Zip Code:__________
PART D
MEDI-CAL ACTIVATION DATE
Per the MHP contract, the Medi-Cal activation date cannot be earlier than the latest of the following dates:
1). Date the provider requested certification: _____________
2). Date the site was operational: ______________
3). Date of the fire clearance (must be within 1 year of the onsite review): ___________
4). Date of the onsite review (The onsite review must be completed within 6 months of the activation date.): ________
5). Is this an out-of-county certification or re-certification?
Yes
No
If the answer to question 5 is yes, enter the name of the host county that conducted the onsite review? ____________________
PART E
RESIDENTIAL SERVICES
Adult Residential H0019 (05/65)
Non-Hospital PHF H2013 (05/20)
Crisis Residential H0018 (05/40)
Number of Beds (maximum of 16):
Note: All residential certifications & recertifications require submission of the residential license and MUST be 16 beds or less.
PART F
OUTPATIENT SERVICES
(12) Hospital Outpatient
Mode (Check ONLY one)
(18) Non-Hospital Outpatient
T1017 (15/01)
S9484 (10/20)
Case Manage/Brokerage
Crisis Stabilization ER
T1017 (15/07)
- Intensive Care Coordination (ICC)
Crisis Stabilization UC
S9484 (10/25)
H2015 (15/30)
Mental Health Services
Day TX Intensive Half Day H2012 (10/81)
- Intensive Home Based Services (IHBS) H2015 (15/57)
H2019 (15/58)
Day TX Intensive Full Day H2012 (10/85)
Therapeutic Behavioral Services (TBS)
Medication Support
H2010(15/60)
Day Rehab. Half Day
H2012 (10/91)
Crisis Intervention
H2011 (15/70)
Day Rehab. Full Day
H2012 (10/95)
AUTHORIZED SIGNATURE (S)
PART G
The above named provider is certified by this agency to participate in the Short-Doyle/Medi-Cal program. I attest that the
above named provider site complies with requirements of the CCR, Title 9, Sections 1810.435-436 and the terms of the
contract between the MHP and the Department.
County Email:
Print name of person completing form
Phone: ________________
Date: _______________
Authorized Signature
Signed by:
County Mental Health Director or Designee
DHCS Compliance Section
E-MAIL OR FAX signed and completed form to: EMAIL:
DMHCertification@dhcs.ca.gov
or by FAX: (916) 440-5497
DHCS COMPLIANCE SECTION APPROVAL TO TRANSMIT DATA TO DHCS
PART H
Date:
10/10/16
DHCS Compliance Section: ________________________________________
DHCS 1735 (Rev. 09/2014)
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