Form Mc 6002 - Direct Provider Certification printable pdf download

Form Mc 6002 - Direct Provider Certification

State of California – Health and Human Services Agency

Department of Health Care Services

DIRECT PROVIDER CERTIFICATION

for Drug Medi-Cal for Fiscal Year 2011-2012

Year-End Claim for Reimbursement

Name and Address of Direct Contract Provider: _________________________________

_________________________________

ADP Contract Number: ________________

County Name: __________________________

I, HEREBY CERTIFY under penalty of perjury that I am the official person responsible for the

administration of Alcohol and Drug Program Services in and for said program; that I have not violated any of

the provisions of Section 1090 through 1096 of the Government Code; that the amount for which

reimbursement is claimed herein is in accordance with Division 10.5, Part 2, Chapter 4 and Chapter 13 of the

California Health and Safety Code; and that to the best of my knowledge and belief this claim is in all aspects

true, correct, and in accordance with the law.

SIGNATURE: ___________________________________

DATE: _______________________

Contract Administrator

EXECUTED AT _______________________, California

FOR STATE USE ONLY

Drug Medi-Cal Funds

1. Claim for Reimbursement

__________________

2. Advances Paid to Date

__________________

3. Less State Admin.

<_________________>

4. Less Share of Cost

<_________________>

5. Net Reimbursement

__________________

DHCS APPROVAL SIGNATURE: _________________________

DATE:

____________________

DHCS MC 6002 (10/12)

Form Mc 6002 - Direct Provider Certification