Audits & Investigations-Financial Review Division Cost Report Forms & Documents
DHCS facility Cost Report forms are available for download below. The Financial Review Division (FRD) audits filed Cost Report forms and updates the Cost Report form list. FRD will update this list as forms become available. The form numbers below provide a direct link to the form.
The forms are Adobe Acrobat PDF files and Microsoft Excel files. Users can digitally fill and print forms or print as a blank form for manual completion. Please note that Adobe Acrobat Reader does not allow saving forms with entered data. If you are unable to access a form and would like to request a hard copy, please contact the Financial Audits Branch, Cost Reporting and Tracking Section I (CRTS) at (916) 650-6696.
Caution—All forms are subject to revision. When preparing a new Cost Report, access the forms from this website to ensure the most current version is used. Submission of outdated forms is subject to rejection by CRTS and will require a resubmission with updated forms.
Update—You must submit the corresponding DocuSign Certification Statement with each Cost Report to avoid rejection.
Long Term Care (LTC) Forms
Individual Intermediate Care Facility for the Developmentally Disabled Habilitative/Nursing (ICF-DDH/N) providers must complete the Cost Report on an annual basis. The Cost Report requires certain disclosure information and financial operating cost to the facility and the Medi-Cal Program.
This 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 costs to the various ICF-DDH/N facilities. You must complete the Home Office Cost Report on an annual basis.
Federally Qualified Health Center/Rural Health Clinic (FQHC/RHC) Forms
Under California State Plan Amendment (SPA) No. 08-003, clinics that provide the services of dental hygienists or dental hygienists in an alternative practice as of January 1, 2008, can elect to be reimbursed under the Prospective Payment System (PPS) Alternate Payment Methodology (APM). This worksheet was designed for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) that included dental hygienist services in their PPS rate as of December 31, 2007. Any clinic that does not fit this description but instead adds dental hygienist services after December 31, 2007, should submit a Change in Scope-of-Services Request (CSOSR) form (DHCS 3096) Electronic submission protocol for FQHC, RHC, Indian Health Services (IHS), and Memorandum of Agreement (MOA) programs.
Instructions for completing the Medi-Cal Worksheets Electronic Submission Protocol for FQHC/RHC/IHS/MOA Providers and FQHC/RHC Home Offices.
This Home Office Cost Report is only for providers that have six or less Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC) facilities. Filing of a Home Office Cost Report is required for freestanding FQHC/RHC which are part of a chain organization or multiple clinic organization that operates at least two or more health care facilities or one FQHC/RHC and a non-healthcare entity/business for Prospective Payment System (PPS) Initial Rate Setting (projected or actual), Rate Setting and Change in Scope-of-Service Request.
This Home Office Cost Report is only for providers that have seven or more Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC) facilities. Filing of a Home Office Cost Report is required for freestanding FQHC/RHC which are part of a chain organization or multiple clinic organization that operates at least two or more health care facilities or one FQHC/RHC and a non-healthcare entity/business for Prospective Payment System (PPS) Initial Rate Setting (projected or actual), Rate Setting and Change in Scope-of-Service Request.
Use this version for providers' Fiscal Period End (FPE) date before January 1, 2021. Federally Qualified Health Centers and Rural Health Clinics complete and submit this Cost Report to determine their facility PPS rate.
Use this version for providers' Fiscal Period End (FPE) date after January 1, 2021. Federally Qualified Health Centers and Rural Health Clinics complete and submit this Cost Report to determine their facility PPS rate.
Use this version for providers' Fiscal Period End (FPE) date before January 1, 2021. Federally Qualified Health Centers and Rural Health Clinics complete and submit this Change in Scope-of-Service Request form to request a PPS rate adjustment if specific criteria are met.
Use this version for providers' Fiscal Period End (FPE) date after January 1, 2021. Federally Qualified Health Centers and Rural Health Clinics complete and submit this Change in Scope-of-Service Request form to request a PPS rate adjustment if specific criteria are met.
Federally Qualified Health Centers and Rural Health Clinics complete and submit this Reconciliation Request form annually in order for DHCS to perform reconciliations for Managed Care and Medicare crossover visits to ensure clinics are paid an amount equal to their PPS rate.
Use this version for all Indian Health Services Memorandum of Agreement (IHS-MOA), 638 Clinics and Tribal Federally Qualified Health Centers (TRIBAL-FQHC) Reconciliation Requests. The Reconciliation Request Form is to be filed annually by clinics for DHCS to perform reconciliations for Managed Care and Medicare crossover visits to ensure that clinics are paid an amount equal to the federal All Inclusive Rate (AIR).
Federally Qualified Health Centers or Rural Health Clinics submit this form to establish or change the managed care differential rate, code 521 T1015 SE (formerly code 18). This form is designed to determine an interim rate to reimburse providers for the difference between their PPS rate and their Medi-Cal Managed Care Plan payments.
Federally Qualified Health Centers or Rural Health Clinics submit this form to establish or change the differential rate for codes 529 G0466-G0470 (formerly code 20). This form is designed to determine an interim rate to reimburse providers for the difference between their PPS rate and their Capitated Medicare Advantage Plan payments.
This package includes (a) FQHC/RHC Initial Rate Setting Application Instructions (pages 1-4), (b) Prospective Payment Election Form (pages 5-6), (c) Election (pages 7-8), (d) Summary of Current Services Provided by Clinic (page 9), and (e) Summary of Healthcare Practitioners (page 10). These forms will be used to establish the initial PPS rate for newly approved FQHC and RHC. If you have any questions regarding this package, please send an email to
clinics@dhcs.ca.gov or contact the Cost Reporting and Tracking Section I at (916) 650-6696.
