Audits & Investigations Forms

Audits and Investigations - Financial Audits Branch Cost Report Forms and Documents

The following is a listing of the various forms used by Financial Audits Branch (FAB). The form numbers listed provide a direct link to the form. The list is not all-inclusive as some forms are not yet available on-line. The list will be updated as forms become available.

The forms are Adobe Acrobat PDF files. The forms can be filled in and printed, or printed as a blank form for manual completion. The forms may also be saved as a blank version for completion later. Please note that Adobe Acrobat Reader does not allow forms with entered data to be saved. If you are unable to access a particular form and would like to request a hard copy, please contact Financial Audits Branch, Audit Review and Analysis Section at (916) 650-6696. Forms and instructions will be sent upon request.

Caution - These forms are subject to revision. Please access the forms from this website to ensure the most current version is used.

Long Term Care Forms	Form Title	Description
DHCS 3076 (12-04) Available as PDF Print and Fill	Intermediate Care Facility for the Developmentally Disabled Habilitative/Nursing (ICF-DDH/N) Cost Report	Cost Report is to be completed by individual ICF-DDH/N providers on an annual basis. The cost report requires certain disclosure information and financial operating cost to the facility and the Medi-Cal Program.
DHCS 3099 (12-04) Available as PDF Print and Fill	Intermediate Care Facility for the Developmentally Disabled Habilitative/Nursing (ICF-DDH/N) Home Office Cost Report	Cost Report is for chain organizations operating or controlling two or more ICF-DDH/N facilities. The cost report requires certain disclosure information of the home office and the distribution of home office cost to the various ICF-DDH/N facilities. The home office cost report is to be completed on an annual basis.

FQHC/RHC Forms	Form Title	Description
DHCS 3089 (03-07) available as Excel Spreedsheet	Medi-Cal Home Office Cost Report - PPS Rate Setting	THIS FORM IS ONLY FOR FQHC AND RHC FACILITIES THAT HAVE 6 OR LESS FACILITIES. Federally Qualified Health Centers or Rural Health Clinics, which are part of a chain organization (multiple clinic organization), submitting a requests to set their new facility PPS rate based on a projected cost report must also submit a Home Office Cost Report specifically designed for New Facility PPS Rate. A Home Office cost report must be submitted if the organization operates two or more health facilities, or one FQHC/RHC and a non-healthcare entity/business. DHCS 3089 (02/07) Instructions.
DHCS 3089.1 (03-07) available as Excel Spreedsheet	Medi-Cal Home Office Cost Report - PPS Rate Setting	THIS FORM IS ONLY FOR FQHC AND RHC FACILITIES THAT HAVE 7 OR MORE FACILITIES. Federally Qualified Health Centers or Rural Health Clinics, which are part of a chain organization (multiple clinic organization), submitting a requests to set their new facility PPS rate based on a projected cost report must also submit a Home Office Cost Report specifically designed for New Facility PPS Rate. A Home Office cost report must be submitted if the organization operates two or more health facilities, or one FQHC/RHC and a non-healthcare entity/business. DHCS 3089 (02/07) Instructions.
DHCS 3090 (03-07) available as Excel Spreedsheet	Medi-Cal Cost Report - PPS Rate Setting	Federally Qualified Health Centers and Rural Health Clinics must complete and submit a Cost Report Forms to apply for their New Facility Projected Prospective Payment System rates. DHCS 3090 (02-07) Instructions
DHCS 3096 (7-04) Available as an Excel Spreadsheet	Federally Qualified Health Center/Rural Health Clinic Change in Scope-of-Services Request	Federally Qualified Health Centers and Rural Health Clinics must complete and submit the Change in Scope-of-Service Request Forms to apply for an adjustment to their Prospective Payment System rates. DHCS 3096 (7-04) Instructions
DHCS 3097 (4-05) Available as an Excel Spreadsheet	Federally Qualified Health Center/Rural Health Clinic Reconciliation Request	The Reconciliation Request Form is to be filed annually by clinics in order for DHCS to perform reconciliations for Managed Care, CHDP, and Medicare crossover visits to ensure that clinics are paid an amount equal to their prospective payment rate. DHCS 3097 (4-05) Instructions
DHCS 3098 (7-04) Available as an Excel Spreadsheet	Federally Qualified Health Center/Rural Health Clinic - Home Office Cost Report for Change in Scope-of-Service Request	Federally Qualified Health Centers or Rural Health Clinics, which are part of a chain organization (multiple clinic organization), submitting Requests for Changes in Scope of Service must also submit a Home Office Cost Report specifically designed for use with request for a Change in Scope of Services forms. A Home Office cost report must be submitted if the organization operates two or more health facilities, or one FQHC/RHC and a non-healthcare entity/business. DHCS 3098 (7-04) Instructions

Acute Care Forms	Form Title	Description
DHCS 3092 (12-05) Available as PDF Print only	Medi-Cal Supplemental Worksheets	Schedule is to be completed by acute care providers on an annual basis. The schedules requires additional disclosure and financial information related to the filing of the Medi-Cal cost report. DHCS 3092 (12-05) Instructions
DHCS 3094 (8-05) Available as PDF Print and Fill	Rate Development Branch (RDB) Schedules	Worksheet is to be completed by individual acute care providers on an annual basis. The worksheets requires certain disclosure information to be forwarded to DHCS Rate Development Branch (RDB). RDB utilizes the reported information to establish the acute provider's all-inclusive rate per discharge limitation. DHCS 3094 (8-05) Instructions
DHCS 3095 (6-05) Available as PDF Print and Fill	Medi-Cal Home Office Cost Report *Note same form as Adult Day Health Care Home Office Cost Report	Cost Report is for chain organizations operating or controlling two or more healthcare facilities - generally acute care or long term care facilities. The cost report requires certain disclosure information of the home and the distribution of home office cost to the various acute or long term care facilities that the home office operates. (Note: In most cases, the Medicare Home Office Cost Report, Form CMS-287-92 may be substituted in lieu of filing the Medi-Cal Home Office Cost Report (DHCS 3095). The home office cost report is to be completed on an annual basis. DHCS 3095 (6-05) Instructions.

Adult Day Health Care Forms	Document Title	Description
DHCS 3095 (6-05) Available as PDF Print and Fill	Medi-Cal Home Office Cost Report (Note: Same form that is located in acute care forms)	Cost Report is for chain organizations operating or controlling two or more healthcare facilities. The cost report requires certain disclosure information of the home and the distribution of home office cost to the various Adult Day Health Care (ADHC) facilities that the home office operates. Note: In most cases, the Medicare Home Office Cost Report, Form CMS-287-92 may be substituted in lieu of filing the Medi-Cal Home Office Cost Report (DHCS 3095). The home office cost report is to be completed on an annual basis. DHCS 3095 (6-05) Instructions.
Adult Day Health Care (ADHC) Cost Report (Form DHCS 9089) Available as a Spreadsheet Release Date: 05/05/2008 Updated Version: 08/25/2008	Adult Day Health Care Cost Report	Adult Day Health Care (ADHC) Centers must complete and submit this form on an annual basis for fiscal periods ending December 31, 2007 and later. An example of a completed ADHC cost report is available on-line. Instructions for completing the ADHC Cost Report (DHCS 9089 INSTRUCTIONS) form is available as a Microsoft Word document. * Please check this website for periodic updates to the Cost Report format and instructions.

Adult Day Health Care Forms

Document Title

Description

DHCS 3095 (6-05) Available as PDF Print and Fill

Medi-Cal Home Office Cost Report (Note: Same form that is located in acute care forms)

Cost Report is for chain organizations operating or controlling two or more healthcare facilities. The cost report requires certain disclosure information of the home and the distribution of home office cost to the various Adult Day Health Care (ADHC) facilities that the home office operates. Note: In most cases, the Medicare Home Office Cost Report, Form CMS-287-92 may be substituted in lieu of filing the Medi-Cal Home Office Cost Report (DHCS 3095). The home office cost report is to be completed on an annual basis. DHCS 3095 (6-05) Instructions.

Adult Day Health Care (ADHC) Cost Report (Form DHCS 9089) Available as a Spreadsheet

Release Date: 05/05/2008

Updated Version: 08/25/2008

Adult Day Health Care Cost Report

Adult Day Health Care (ADHC) Centers must complete and submit this form on an annual basis for fiscal periods ending December 31, 2007 and later. An example of a completed ADHC cost report is available on-line. Instructions for completing the ADHC Cost Report (DHCS 9089 INSTRUCTIONS) form is available as a Microsoft Word document.

* Please check this website for periodic updates to the Cost Report format and instructions.

FAB Documents	Document Title	Description
Administrator Compensation Ranges Available as PDF Print only	Administrator Compensation for California Long Term Care Facilities	This document reflects the administrator compensation ranges for freestanding skilled nursing facilities level -- B (FS/NF-B) in California. The administrator compensation ranges are divided into 3 tables according to bed sizes (1-59 beds, 60-99 beds, over 100+ beds).