Forms Mc 6003, Mc 6015, And Mc 6016 - Instructions For Completing Dmc Forms For Odf Group And Individual - Alcohol And Drug Page 3
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3State of California – Health and Human Services Agency
Department of Health Care Services
Line 04c4:
For the reporting period (July through June), enter the number of total
units submitted for reimbursement for Non-Title XIX Minor Consent only
and the number of those units that were denied.
Line 15a:
In the shaded field, enter the total amount of Revenue/Fees (Share of
Cost).
Line 15b:
In the shaded field, enter the total amount of Revenue from Insurance /
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Party Fees.
Save, Print and Submit to your analyst with the year-end certification form.
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