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Get CA DHCS 6207 2014-2024

Ev. 7/14) i GENERAL INSTRUCTIONS FOR COMPLETING THE MEDI-CAL DISCLOSURE STATEMENT • • • • • DO NOT USE staples on this form or on any attachments. Do not use a pencil, correction tape, correction fluid, highlighter pen, etc. on this form. If you must correct an entry, the applicant or provider must initial and date the correction in ink. Do not leave any questions, boxes, lines, etc., blank. Check or write “N/A” if not applicable to you. To review the Title 22 provider enrollm.

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