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Forms Mc 6005 And Mc 6006 - Instructions For Completing Dmc Forms For Res - Perinatal

State of California – Health and Human Services Agency

Department of Health Care Services

INSTRUCTIONS FOR COMPLETING DMC FORMS FOR

RES – PERINATAL

(Forms MC 6005 and MC 6006)

The filename for the FY 2011-12 Cost Report Forms is “1112_DP_RES_P”. A separate

worksheet has been created for each document within the file. The worksheets are “Data

Entry Sheet”, “7895RES-P” and “7990RES-P”. Enter data only in the shaded fields on the

Data Entry Sheet, all other fields are calculated automatically. Do not change the

formulas.

WORKSHEET “DATA ENTRY SHEET” (MC 6005)

Heading: Enter the County Name, Contractor/Provider Name, Contract Number, 4-digit

Drug Medi-Cal Provider Number, and the 6-digit Provider Number. This information will be

automatically transferred to all other documents in file.

Cost Information: Enter the specific cost information for the following areas: Private Pay

and Drug Medi-Cal.

Unit Information: Enter the specific unit information for the following areas: Private Pay

and Drug Medi-Cal.

WORKSHEET “7895RES-P” – NO DATA ENTRY REQUIRED (part of MC 6005)

This worksheet identifies the total funding.

WORKSHEET “7990RES-P” – NO DATA ENTRY REQUIRED (MC 6006)

This worksheet identifies the DMC funding split between Federal and Realignment share.

Forms Mc 6005 And Mc 6006 - Instructions For Completing Dmc Forms For Res - Perinatal