State of California—Health and Human Services Agency Department of Heatlh Care Services

MEDI-CAL COST REPORT

CHANGE IN SCOPE-OF-SERVICE REQUEST

FREESTANDING

PROSPECTIVE PAYMENT SYSTEM (PPS)

CLINIC NAME: 0

NPI NUMBER: 0

FISCAL PERIOD ENDED: 12/30/1899

DHCS 3096 (05/2021) Page 1 of 12

State of California—Health and Human Services Agency Department of Health Care Services
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FEDERALLY QUALIFIED HEALTH CENTER (FQHC)/RURAL HEALTH CLINIC (RHC)
PROSPECTIVE PAYMENT SYSTEM (PPS)—CHANGE IN SCOPE-OF-SERVICE REQUEST
STATISTICAL DATA AND CERTIFICATION STATEMENT
PART A—GENERAL INFORMATION
1. FQHC/RHC Name: 2. Date of Earliest Scope-of-Service Change: 3. Date Submitted: A. Voluntary
A. Voluntary
4. FQHC/RHC Street Address: 5. City, State, and Zip Code: 6. NPI Number: B. Proprietary
B. Proprietary
7. Preparer Name or Contact Person: 8. Title: 9. Email: B. Proprietary
B. Proprietary
10. Telephone Number: 11. Fiscal Year Begin: 12. Fiscal Year End: C. Governme
C. Governme
13. Type of Control: (Select from drop-down menu) 14. Other: (Specify): 15. Clinic Type: (Select from drop-down menu) C. Governme
C. Governme

Owner(s) of this facility and percentage owned (Owner means having at least 5% interest—Direct or Indirect)

16. Provider Name 17. Address/Location 18. NPI

FEDERALLY
RURAL HEA

Yes

Related Party: Other providers of service including FQHC/RHCs, hospitals, skilled nursing facilities, home health agencies, suppliers, No
pharmacies, or other entities that are owned or related through common ownership or control to the individuals or entities listed in item 5.
N/A

19. Provider Name 20. Address/Location 21. NPI

List names of physicians furnishing services for the facility, whether employed by or under agreements and their Medi-Cal billing numbers.

22. Physician Name 23. Billing/NPI Number

Statement of Compensation for Owners and Relatives

24. Name 25. Title 26. % of Ownership Interest

27. Average Hours Worked per Week 28. Compensation Included in Cost Report

DHCS 3096 (05/2021) Page 2 of 12

State of California—Health and Human Services Agency Department of Health Care Services

Type of Scope-of-Service Change (Select from Drop Down Menu 29 to 38 )

29. The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective paymentsystem (PPS) rate, or a deletion of
an FQHC or RHC service that is incorporated in the baseline PPS rate.

30. Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any service for FQHC or
RHC, including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or
clinic.

31. A change in service due to amended regulatory requirements or rules.

32. Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching
services to interns and residents.

33. A change in service resulting from relocating or remodeling an FQHC or RHC.

34. An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or
AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.

35. Any changes in the scope of a project approved by the federal Health Resources and Service Administration (HRSA).

36. Any changes in FQHC or RHC services, or in the provider mix of an FQHC or RHC or one of its sites.

37. The deletion of a Medi-Cal covered service previously provided by the FQHC or RHC (such as deleting pharmacy services, and any other
Medi-Cal covered services that do not require a face-to-face visit with an FQHC or RHC provider, e.g., laboratory, x-rays, etc.).

38. A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.

39. Briefly describe the change(s) in scope-of-service provided, and how such change(s) in the type, intensity, duration, or amount of service,
or any combination(s) thereof. (Attach a separate sheet if necessary)

PART B—CERTIFICATION BY OFFICER OF THE HOME OFFICE

Intentional misrepresentation or falsification of any information contained herein may be punishable by fine and/or imprisonment under Federal and State laws:
(42 CFR 1003.102 "Basis for Civil Money Penalties and Assessments"; 18 U.S.C. 1347 "Health Care Fraud"; California Welfare and Institutions Code 14123.25 "Civil
Money Penalties for Fraudulent Claims"; and Title 22 51485.1 "Civil Money Penalties") of the California Code of Regulations. 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. If claims are made in
violation of an agreement with the State, you or your organization may be subject to civil money penalty assessments in accordance with the W&I Code, Section 14123.2.

Certification by Officer or Administrator of FQHC/RHC:

I, ___________________________________________, certify under penalty of purgery as follows:
Print Name
I am an official of the subject clinic 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 W&I Code.

Refer to the corresponding Certification Statement located on the DHCS Forms & Publications webpage. We will reject any cost report filed without a completed
certification statement signed through DocuSign. The individual E-signing this statement must be an officer or or other authorized person.
https://www.dhcs.ca.gov/formsandpubs/forms/Pages/AuditsInvestigationsForms.aspx

Follow the e-file Medi-Cal Worksheets Submission Protocol for submission of FQHC/RHC Home Offices, include audited financial statements, with
accompanying notes, a trial balance of the home office general ledger and cost report working papers to the applicable inbox below:

You will receive an email response.

[email protected]
[email protected]
For assistance/questions please contact CRTS at (916) 650-6696 or [email protected]

DHCS 3096 (05/2021) Page 3 of 12

State of California—Health and Human Services Agency Department of Health Care Services
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FEDERALLY QUALIFIED HEALTH CENTER (FQHC)/RURAL HEALTH CLINIC (RHC)
PROSPECTIVE PAYMENT SYSTEM (PPS)—CHANGE IN SCOPE-OF-SERVICE REQUEST
TRIAL BALANCE OF EXPENSES
WORKSHEET 1
Use the arrow keys to navigate through the workbook PAGE 1 of 2
Clinic Name: NPI: Fiscal Period:

0 0 From: 12/30/1899 Through: 12/30/1899

FQHC/RHC Health Care Staff Costs

Reclassifications
Adjustments from
Total from W/S 1A Reclassified Net Expense
COST CENTER Compensation Other W/S 1B Increases
(Columns 1 + 2) Increases (Columns 3 + 4) (Columns 5 + 6)
(Decreases)
(Decreases)

1 2 3 4 5 6 7

1. Physicians; MD $ - $ - $ -
2. Physicians Contracted $ - $ - $ -
3. Physician Assistants; PA $ - $ - $ -
4. Nurse Practitioners; NP $ - $ - $ -
5. Certified Midwife, CNM $ - $ - $ -
6. Other (Specify) $ - $ - $ -
7. Other (Specify) $ - $ - $ -
8. Other (Specify) $ - $ - $ -
9. Other (Specify) $ - $ - $ -
10. Other (Specify) $ - $ - $ -
11. Other (Specify) $ - $ - $ -
12. Other (Specify) $ - $ - $ -
13. Subtotal—Health Care Staff Costs (Lines 1—12) $ - $ - $ - $ - $ - $ - $ -
FQHC/RHC Health Care Costs—Other
14. Pharmacy $ - $ - $ -
15. Dental $ - $ - $ -
16. Medical Supplies $ - $ - $ -
17. Laboratory $ - $ - $ -
18. Radiology $ - $ - $ -
19. Professional Liability Insurance $ - $ - $ -
20. Home Office Costs—Health Care $ - $ - $ -
21. Other (Specify) $ - $ - $ -
22. Other (Specify) $ - $ - $ -
23. Other (Specify) $ - $ - $ -
24. Other (Specify) $ - $ - $ -
25. Other (Specify) $ - $ - $ -
26. Other (Specify) $ - $ - $ -
27. Other (Specify) $ - $ - $ -
28. Subtotal—Other Health Care Costs (Lines 14—27) $ - $ - $ - $ - $ - $ - $ -

29. Total Health Care Costs (Sum Lines 13 & 28) $ - $ - $ - $ - $ - $ - $ -

DHCS 3096 (05/2021) Page 4 of 12

State of California—Health and Human Services Agency Department of Health Care Services
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FEDERALLY QUALIFIED HEALTH CENTER (FQHC)/RURAL HEALTH CLINIC (RHC)
PROSPECTIVE PAYMENT SYSTEM (PPS)—CHANGE IN SCOPE-OF-SERVICE REQUEST
TRIAL BALANCE OF EXPENSES
WORKSHEET 1
Use the arrow keys to navigate through the workbook PAGE 2 of 2
Clinic Name: NPI: Fiscal Period:

0 0 From: 12/30/1899 Through: 12/30/1899

FQHC/RHC Overhead-Facility Costs

Reclassifications
Adjustments from
Total from W/S 1A Reclassified Net Expense
COST CENTER Compensation Other W/S 1B Increases
(Columns 1 + 2) Increases (Columns 3 + 4) (Columns 5 + 6)
(Decreases)
(Decreases)

1 2 3 4 5 6 7

30. Rent $ - $ - $ -
31. Insurance $ - $ - $ -
32. Interest Expense $ - $ - $ -
33. Utilities $ - $ - $ -
34. Depreciation—Building $ - $ - $ -
35. Depreciation—Equipment $ - $ - $ -
36. Housekeeping and Maintenance $ - $ - $ -
37. Property Tax $ - $ - $ -
38. Minor Equipment $ - $ - $ -
39. Home Office Costs—Facility $ - $ - $ -
40. Other (Specify) $ - $ - $ -
41. Other (Specify) $ - $ - $ -
42. Subtotal—Facility Costs (Line 30—41) $ - $ - $ - $ - $ - $ - $ -

FQHC/RHC Overhead—Administrative Costs

43. Office Salaries $ - $ - $ -

44. Depreciation—Office Equipment $ - $ - $ -
45. Office Supplies $ - $ - $ -
46. Legal $ - $ - $ -
47. Accounting $ - $ - $ -
48. Insurance (specify in attachment): $ - $ - $ -
49. Telephone $ - $ - $ -
50. Fringe Benefits and Payroll Taxes $ - $ - $ -
51. Home Office Costs—Administrative $ - $ - $ -
52. Other (Specify) $ - $ - $ -
53. Other (Specify) $ - $ - $ -
54. Subtotal—Adminstrative Costs (Line 43—53) $ - $ - $ - $ - $ - $ - $ -

55. Total FQHC/RHC Overhead Costs (subject to allocation) $ - $ - $ - $ - $ - $ - $ -

(Sum of Lines 42 & 54)
56. Nonreimbursable Costs (Specify): $ - $ - $ -
57. Other (Specify) $ - $ - $ -
58. Other (Specify) $ - $ - $ -
59. Subtotal—Nonreimbursable Costs (Line 56—58) $ - $ - $ - $ - $ - $ - $ -
60. Total FQHC—RHC Costs (Sum of Line 29, 55, & 59) $ - $ - $ - $ - $ - $ - $ -
DHCS 3096 (05/2021) Page 5 of 12
State of California—Health and Human Services Agency Department of Health Care Services
Use the arrow keys to navigate through the workbook
FEDERALLY QUALIFIED HEALTH CENTER (FQHC)/RURAL HEALTH CLINIC (RHC)
PROSPECTIVE PAYMENT SYSTEM (PPS)—CHANGE IN SCOPE-OF-SERVICE REQUEST
RECLASSIFICATION OF EXPENSES
WORKSHEET 1A
Clinic Name: NPI: Fiscal Period:

0 0 From: 12/30/1899 Through: 12/30/1899

Increase Decrease

Explanation of Entry
Code Cost Center Line # Amount Cost Center Line # Amount

1 2 3 4 5 6 7
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26. Total Reclassifications (Col. 4 & 7 must equal) $ - $ -
Column 1: Use sequential lettering system to idetify individual reclassifications; i.e. A. B. C.
Column 4 and Column 7: Transfer amounts to Worksheet 1, Column 4, Line numbers as appropriate.

DHCS 3096 (05/2021) Page 6 of 12

State of California—Health and Human Services Agency Department of Health Care Services
Use the arrow keys to navigate through the workbook
FEDERALLY QUALIFIED HEALTH CENTER (FQHC)/RURAL HEALTH CLINIC (RHC)
PROSPECTIVE PAYMENT SYSTEM (PPS)—CHANGE IN SCOPE-OF-SERVICE REQUEST
ADJUSTMENTS OF EXPENSES
WORKSHEET 1B
Clinic Name: NPI: Fiscal Period: From: Through:

0 0 12/30/1899 12/30/1899

Basis for
Amount Increase
Explanation of Entry Adjustment Cost Center Line Number
(Decrease)
(A or B)

Col. 1 Col. 2 Col. 3 Col. 4

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17. Total (Sum of Line 1—16) $ -
Basis for Adjustment
A = Cost (Including applicable overhead as appropriate)
B = Amount received (If cost cannot be determined)
Amount
Column 2: Transfer to Worksheet 1, Column 6, Line number as appropriate.

DHCS 3096 (05/2021) Page 7 of 12

State of California—Health and Human Services Agency Department of Health Care Services
Use the arrow keys to navigate through the workbook
FEDERALLY QUALIFIED HEALTH CENTER (FQHC)/RURAL HEALTH CLINIC (RHC)
PROSPECTIVE PAYMENT SYSTEM (PPS)—CHANGE IN SCOPE-OF-SERVICE REQUEST
ADJUSTMENTS OF EXPENSES
Use the arrow keys to navigate through the workbook WORKSHEET 2
Clinic Name: NPI: Fiscal Period: From: Through:
0 0 12/30/1899 12/30/1899

PART A—DETERMINATION OF OVERHEAD APPLICABLE TO FQHC/RHC SERVICES Amount

1. Total FQHC/RHC Health Care Services Cost (W/S 1, Pg. 1, Line 29, Col. 7) $ -
2. Nonreimbursable FQHC/RHC Costs Excluding Overhead (W/S 1, Pg. 2, Line 59, Col. 7) $ -
3. Cost of All Services Excluding Overhead (Sum of Lines 1 and 2) $ -
4. Percentage of Nonreimbursable FQHC/RHC Costs (Line A2 divided by Line A3) 0.00%
5. Total Overhead—(W/S 1, Pg.2, Line 55, Col. 7) $ -
6. Overhead Applicable to Non-Reimbursable FQHC/RHC Costs (Multiply Line A5 by Line A4) $ -
7. Overhead Applicable to FQHC/RHC Services (Line A5 less Line A6) $ -
8. Total Cost of FQHC/RHC Services (Line A1 plus Line A7) $ -
PART B—DETERMINATION OF FQHC/RHC RATE
1. Total FQHC/RHC Cost (PART A, Line 8) $ -
2. Total FQHC/RHC Visits (Worksheet 6, Column 5, Line 20) 0
3. FQHC/RHC Cost Per Visit (Line B1 divided by Line B2) $ -
PART C—DETERMINATION OF PPS RATE ADJUSTMENT
1. FQHC/RHC Cost Per Visit (PART B, Line 5) $ -
2. Current PPS Rate Per Visit ( See note 1)
3. Net Increase or Decrease in FQHC/RHC Rate ( Line C1 less Line C2 ) Show decrease in parenthesis $ -
If Line C3 is greater than zero (Line C1 is greater than Line C2), proceed to Line C4.
If Line C3 is less than zero ( Line C1 is less than Line C2), proceed to Line C5.

PART D—FQHC/RHC RATE CHANGE

1. FQHC/RHC Rate Increase or Decrease (Part C Line 3) Show Decreases in Parenthesis $ -
2 2. FQHC/RHC Rate Increase or Decrease Adjustment of 20% (Line D1 x 20%) $ -
3. FQHC/RHC Rate Increase or Decrease After Adjustment of 20% ( Line D1 less Line D2 ) $ -
4. Current PPS Rate Per Visit ( From Line C2) $ -
5. New PPS Rate (Line D3 plus Line D4) $ -
Notes:
1 The current PPS rate per visit means the PPS rate per visit in effect on the last day of the reporting period during
which the scope-of-service change occurred.
2 Reporting an increase that meets or exceeds the threshold of 1.75% is optional. If your rate decreased more
than 2.5% AND you have experienced a decrease in the scope-of-services, filing is mandatory.

DHCS 3096 (05/2021) Page 8 of 12

State of California—Health and Human Services Agency Department of Health Care Services
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FEDERALLY QUALIFIED HEALTH CENTER (FQHC)/RURAL HEALTH CLINIC (RHC)
PROSPECTIVE PAYMENT SYSTEM (PPS)—CHANGE IN SCOPE-OF-SERVICE REQUEST
VISITS, REVENUE AND EXPENDITURES

Use the arrow keys to navigate through the workbook WORKSHEET 3

NPI: Fiscal Period: From: To:
Clinic Name:
0 0 12/30/1899 12/30/1899

RELATED
PROGRAM FUNDING SOURCES VISITS RELATED EXPENDITURES
REVENUES

1. Medi-Cal for Billing Codes 01, 03, & 04

2. Medi-Cal Crossovers for Billing Code 02
3. Medi-Cal Managed Care for Billing Code 18
4. Medi-Cal MAP Crossovers—Billing Code 20
5. Medicare for Crossovers—Codes 02 & 18 N/A: These
6. Medi-Cal Managed Care Plans—Code 18 visits are
7. Medicare Advantage Plans (MAP)—Code 20 included above.
8. Straight Medicare (Including Part D)
9. Straight Medicare HMO (MAP)
10. Other Managed Care HMO's
11. Private
12. Self Pay—Sliding Fee Scale
13. Family Planning
14. CHDP History/Physicals
15. EPSDT
16. CPSP
17. EAPC
18. Acupuncturist
19. Marriage Family Therapist
20. Other Reimbursable (specify):
21. Other (Specify):
22. Other (Specify):
23. Reimbursable Grants (specify):
24. Other (Specify):
25. Other (specify):
26. Nonbillable Activities *:
27. Counselors *
28. Nutritionist *
29. Other (Specify):
30. Other (Specify):
31. Nonreimbursable Activities **:
32. WIC
33. Health Education
34. Community Outreach
35. Other (Specify):
36. TOTALS (Sum of Lines 1—35) 0 $ - $ -
* Nonbillable Practitioners Visits **Nonreimbursable Visits
Total Visits (Column 1) must agree with Total Visits on Worksheet 5, Column 2, Line 29.
Total Revenues (Column 2) must agree with the general ledger and/or audited financial statements.
Nonreimbursable Related Expenditures must agree with Worksheet 1, Page 2, Lines 56—58.

DHCS 3096 (05/2021) Page 9 of 12

State of California—Health and Human Services Agency Department of Health Care Services
Use the arrow keys to navigate through the workbook
FEDERALLY QUALIFIED HEALTH CENTER (FQHC)/RURAL HEALTH CLINIC (RHC)
PROSPECTIVE PAYMENT SYSTEM (PPS)—CHANGE IN SCOPE-OF-SERVICE REQUEST
SUMMARY OF SERVICES
Use the arrow keys to navigate through the workbook WORKSHEET 4
Clinic Name: Fiscal Period:
0
NPI:
0 From: 12/30/1899 Through: 12/30/1899
Please indicate which services are provided and NO* YES**
where. Provide Contractor's Name.
ON-SITE OFF-SITE CONTRACTOR NAME

1. Medical
2. Dental
3. Dental Hygienist
4. X-ray
5. Laboratory
6. Pharmacy
7. Nutritional
8. Psychology
9. Psychiatry
10. Social/Behavioral Health Services
11. Drug Counseling
12. Education
13. CPSP
14. Outreach
15. Optometry
16. Chiropractic
17. Podiatry
18. Physical Therapy
19. Occupational Therapy
20. Treatment Room
21. Surgery/Recovery
22. Anesthesiology
23. Radiology
24. Nuclear Med/CT
25. Central Supplies
26. Radiosotope
27. Electrocardiology
28. Marriage Family Therapy
29. Acupuncture
30. Women, Infants and Children (WIC)
31. Other (Specify):
32. Other (Specify):
*NO = Service is NOT provided by the clinic.
**YES ON-SITE = Service is provided within '4-walls' of clinic.
**YES OFF-SITE = Service is provided outside clinic by contractual arrangement (include contractor's
name).

DHCS 3096 (05/2021) Page 10 of 12

State of California—Health and Human Services Agency Department of Health Care Serv ices
Use the arrow keys to navigate through the workbook
FEDERALLY QUALIFIED HEALTH CENTER (FQHC)/RURAL HEALTH CLINIC (RHC)
PROSPECTIVE PAYMENT SYSTEM (PPS)—CHANGE IN SCOPE-OF-SERVICE REQUEST
SUMMARY OF SERVICES
WORKSHEET 5
Clinic Name: NPI: Fiscal Period:
From: 12/30/1899
0 0 Through: 12/30/1899
1 2 3 4

# of VISITS
HEALTH CARE STAFF FTEs ON-SITE OFF-SITE

1. Physicians; MD
2. Physicians—Contracted
3. Physician Assistants; PA
4. Nurse Practitioners; NP
5. Certified Nurse Midwife; CNM
6.
7. Doctor of Dental Surgery; DDS
8. Registered Dental Hygienist; RDH
9. Doctor of Podiatric; DPM
10. Doctor of Optometry; OD
11. Doctor of Chiropractic's; DC
12. Doctor of Psychiatry; MD
13. Visiting Nurse
14. Clinical Psychologist
15. Licensed Clinical Social Worker; LCSW
16. Comprehensive Perinatal Health Worker
17. Acupuncturist
18. Marriage Family Therapist
19. Other (Specify):
20. Counselors *
21. Nutritionist *
22. WIC **
23. Health Education **
24. Community Outreach **
25. Other (Specify) **:
26. Other (Specify) **:
27. Other (Specify) **:
28. Other (Specify) **:
29. TOTALS (Sum of Lines 1—28) 0.00 0
Full Time Equivalent (FTE) assumes 2,080 hours worked in Patient Care activities (40 hrs/week for 52 weeks). Only
include the Productive Time worked. Exclude all time spent in nonpatient care activities including administrative time.

* Nonbillable Practitioners Visits **Nonreimbursable Visits

Columns 1 and 2 totals must agree with totals on Worksheet 6, Columns 1 and 2.

DCHS 3096 (05/2021) Page 11 of 12

State of California—Health and Human Services Agency Department of Health Care Services
Use the arrow keys to navigate through the workbook
FEDERALLY QUALIFIED HEALTH CENTER (FQHC)/RURAL HEALTH CLINIC (RHC)
PROSPECTIVE PAYMENT SYSTEM (PPS)—CHANGE IN SCOPE-OF-SERVICE REQUEST
SUMMARY OF SERVICES
WORKSHEET 6
Clinic Name: NPI: Fiscal Period:

0 0 From: 12/30/1899 Through: 12/30/1899

1 2 3 4 5

Full Time Productivity Minimum Visits Visits of PPS

HEALTH CARE STAFF Actual Visits
Equivalents Standard (Col. 1 x Col. 3) Rate Calculation

1. Physicians; MD 0.00 0 4,200 0

2. Physicians—Contracted 0.00 0 4,200 0 The larger # of
3 Physician Assistants; PA 0.00 0 2,100 0 Visits on Line 6, is
4. Nurse Practitioners; NP 0.00 0 2,100 0 used on Col. 5
5. Certified Nurse Midwife; CNM 0.00 0 2,100 0
6. Subtotal (Sum of Lines 1—5) 0.00 0 N/A 0 0
7. Doctor of Dental Surgery; DDS 0.00 0 0
8. Registered Dental Hygienist; RDH 0.00 0 0
9. Doctor of Podiatric; DPM 0.00 0 0
10. Doctor of Optometry; OD 0.00 0 0
11. Doctor of Chiropractic's; DC 0.00 0 There are no Productivity Standards 0
12. Doctor of Psychiatry; MD 0.00 0 for healthcare staff in these positions, 0
13. Visiting Nurse 0.00 0 therefore no minimum visit 0
14. Clinical Psychologist 0.00 0 requirement. 0
15. Licensed Clinical Social Worker; LCSW 0.00 0 0
16. Comprehensive Perinatal Health Worker 0.00 0 0
17. Acupuncturist 0.00 0 0
18. Marriage Family Therapist 0.00 0 0
19. Other (Specify): 0.00 0 0
20. Total Reimbursable Visits (Sum of Lines 6—19) 0.00 0 0
21. Nonbillable/Nonreimbursable Visits 0.00 0 0
22. Total Visits (Sum of Lines 20 + 21) 0 0 0
Columns 1 & 2 above must agree with Worksheet 5.

Total Visits to be used for rate setting purposes is Column 5, Line 20—transfer to Worksheet 2, Part B, Line 2.

NOTE: If a provider can reasonably justify not meeting these standards then an exception may be granted. Attach a detailed statement indicating why standards
were not met. The Department will determine if a more reasonable standard should be applied.

DHCS 3096 (05/2021) Page 12 of 12