Form Dhcs 3076 - Supplemental Cost Report Schedule A For Intermediate Care Facilityfor The Developmentally Disabled (Habilitative Or Nursing) Adult Day Services And Related Transportation Cost

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State of California—Health and Human Services Agency
Department of Health Care Services
SUPPLEMENTAL COST REPORT SCHEDULE A
FOR
INTERMEDIATE CARE FACILITYFOR THE DEVELOPMENTALLY DISABLED
(HABILITATIVE OR NURSING)
ADULT DAY SERVICES AND RELATED TRANSPORTATION COST
GENERAL INFORMATION AND CERTIFICATION
1. Name of Facility
2. State License Number
3. N P I N u m b e r
4. Street Address
5. City
6. ZIP Code
7. Mailing Address
8. City
9. ZIP Code
10. Administrator
11. Report Contact Person
12. E-mail Address
13. Phone Number
14. Mailing Address: Street or P.O. Box
15. City
16. ZIP Code
17. Reporting Period Began
18. Reporting Period End
19. Name of Home Office (If Applicable)
20. Home Office Phone Number
21.
CERTIFICATION
I,
, certify under penalty of perjury as follows:
That I am an official of
and am duly authorized to sign this certification and
that to the best of my knowledge and information, I believe each statement and amount in the accompanying report to be
true, correct, and in compliance with Section 14161 of the California Welfare and Institutions Code.
Signature
Date
Title
Address
Please be advised that continued submission of claims or cost reports for items or services which were not provided as
claimed, are not reimbursable under the Medi-Cal program, or claimed in violation of an agreement with the State, may
subject you (your organization) to civil money penalty assessment in accordance with the Welfare and Institutions Code,
Section 14123.2.
Mail the original copy to: LTCATRT@dhcs.ca.gov
22.
U.S. Mail
FedEx, UPS, etc.
California Department of Health Care Services
California Department of Health Care Services
Fee-For-Service Rates Development Division
Fee-For-Service Rates Development Division
Long Term Care Section
Long Term Care Section
Attention: LTC Reimbursement Unit
Attention: LTC Reimbursement Unit
1501 Capitol Avenue, MS 4600
1501 Capitol Avenue, Suite 71.3052, MS 4600
P.O. Box 997417
Sacramento, CA 95814
Sacramento, CA 95899-7417
DHCS 3076-Supp A (01/2016)

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