FOR TRANSFEREE APPLICANTSigned this day of day of month monthin California name of county where signed signature of transferee applicantdate declare under penalty of perjury unde ID: 897542
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1 ��State of CaliforniaDepar
��State of CaliforniaDepartment of Health Care ServicesHealth and Human Services Agency��DHCS 6(Rev. 5/17)Page 2 of 2 FOR T RANSFEREE APPLICANT Signed this _______________, ________________ day of (day of month) (month) in _________________________________, California. (name of county where signed) _______________________________________________________ __________________ (signature of transferee applicant(date) ____________________________________________, declare under penalty of perjury under the (name of transferee applicant)laws of the State of California that I meet all of the requirements to be a MediCal provider. Executed at _____________________________, ______________________on _________________(city) (state) (date) Notary Public Notarization is required. The Certificate of Acknowledgment signethe Notary Public must be in the rm specified in Section 1189 of the Civil Code. Thislettershouldpostmarkedlaterthanfive(5)days a
2 ftertheoccurrencethe circumstancelistedC
ftertheoccurrencethe circumstancelistedCaliforniaCode ofRegulations(CCR), TitleSection51000.30(b).Thetransfereeapplicant must submit a completeapplication package receivedtheartmentwithindaystheoccurrence a circumstancelisted(b)(1),(b)(2),(b)(6),(b)(7. Thisrequired TitleSection51000.30(b). ��State of CaliforniaDepartment of Health Care ServicesHealth and Human Services Agency��DHCS 6(Rev. 5/17)Page 1 of 2 UCCESSOR LIABILITY WITH JOINT AND SEVERAL LIABILITYAGREEMENT This seion is signedanddatedprovidertransferorandtransfereeapplicant: ___________________________________ andlegal name o ransferee applicantacknowledgthat theMedil Provider Agreement between e provider transferor d e artment of Health Care Service(DHCS) r e businessoperations at (street address, city and nine FOR PROVIDER TRANSFEROR Signed this _______________, ________ ________________ day of (day of month) (month) (year) in (name of county where signed) _______________________________________________________ __________________ (date) ransferor