Fillable DISCLOSURE TO DHCS State of California Department of (Department of Health Care Services)

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DISCLOSURE TO DHCS State of California Department of (Department of Health Care Services)

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State of California
Health and Human Services Agency
Department of Health Care Services
DISCLOSURE TO DHCS
Pursuant to Health and Safety Code (HSC) Section 11833.05(a), applicants and licensed or certified
alcohol and drug (AOD) programs are required to disclose specified information to DHCS. This
includes:
1. Any ownership, control of, or financial interest in a recovery residence as defined in HSC
Section 11833.05(c);
2. Any contractual relationship with an entity that provides professional services, addiction
treatment, or recovery services to clients of programs licensed or certified by DHCS, if the
entity is not part of the program licensed or certified by DHCS.
Disclosures must be made at the time of:
1. Application for initial licensure or certification;
2. Application for extension of licensure or certification; AND
3. Whenever a licensed or certified program acquires or starts a relationship that meets the
requirements of HSC Section 11833.05(a).
To assist programs with meeting the disclosure requirement, programs may use DHCS Form 5140 for
disclosure to DHCS or may develop their own disclosure form provided it contains, at a minimum, all
the information requested in DHCS Form 5140. The disclosure form must also be completed, signed
and dated by the individual authorized to represent the provider.
If a program fails to disclose the required information, DHCS may suspend or revoke the license or
certification of the AOD program.
Instructions:
Legal Entity Name: Enter the legal entity name of applicant, licensed or certified program.
Corporation: For a corporation or Limited Liability Company (LLC) of any type this must match
exactly the name of the corporation (or LLC) as filed with the Secretary of State (SOS) and on
the entities articles of incorporation.
Partnership: For a partnership that has filed a certification of limited partnership with the SOS,
this must match exactly the name filed.
Sole Proprietor: For a sole proprietorship, this must be the full legal name of the sole
proprietor.
DHCS 5140 (Rev.2/19)
Provider Number(s): Enter all DHCS licensed or certified facility provider numbers associated with
the legal entity. Enter N/A if Not applicable.
Entity Legal Business Name: Enter the name of the recovery residence or entity that provides
professional, addiction, or recovery services to clients.
Service Location Address: Enter the physical address of the recovery residence or entity that
provides professional, addiction, or recovery services to clients. Enter N/A if Not applicable.
Entity Business Type: Enter the entity business type for entity being disclosed (e.g. hospital, clinic,
counseling center, transportation, recovery residence if disclosed entity is a sober living home, sober
living environment, or unlicensed alcohol and drug free residence).
Relationship with Entity: Enter the relationship between the applicant, licensed or certified program
legal entity and the entity being disclosed. Include all that apply.
o Ownership
o Control of
o Financial Interest
o Contractual Relationship
Certification and Assurances
I certify that I have read, understand, and will comply with the regulations and/or standards that
govern the operation of the program. The information contained in this disclosure statement is
accurate, true and complete in all material aspects.
If the applicant is a sole proprietor, the application shall be signed by the proprietor; if the applicant is
a partnership, the application shall be signed by each partner, and if the applicant is a firm,
association, corporation, county, city, public agency or other governmental entity, the application shall
be signed by the chief executive officer or an individual authorized to represent the provider. Attach
additional signature pages if necessary.
CIVIL CODE § 1798.17 AND THE PRIVACY ACT OF 1974, 5 U.S.C. 552a, PROVIDES
PROTECTION TO INDIVIDUALS BY ENSURING THAT PERSONAL INFORMATION COLLECTED
BY STATE AGENCIES IS LIMITED TO THAT WHICH IS LEGALLY AUTHORIZED AND
NECESSARY AND IS MAINTAINED IN A MANNER WHICH PRECLUDES UNWARRANTED
INTRUSIONS UPON INDIVIDUAL PRIVACY.
Only one signature is required unless applicant is a partnership.
Signature of
Authorized Individual
Print Name
Title
Date
DHCS 5140 (Rev.2/19)
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DISCLOSURE TO DHCS
(Use additional pages if necessary)
In the table below, please list all:
1. Ownership, control of, or financial interest in a recovery residence.
2. Contractual relationship with an entity that provides professional services, addiction treatment, or recovery services to
clients of programs licensed or certified by DHCS, if the entity is not part of the program licensed or certified by DHCS.
Legal Entity Name: ______________________________________________________________________________
DHCS Provider Number(s): _________________________________________________________________________
Use this Section to Disclose Entities
(Include Doing Business As
Service Location Address
(Include County)
Entity Business Type Relationship with Entity
(Include all that apply)
DHCS 5140 (Rev.2/19)
Use this Section to Disclose Entities
(Include Doing Business As
Service Location Address
(Include County)
Entity Business Type Relationship with Entity
(Include all that apply)
DHCS 5140 (Rev.2/19)
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DISCLOSURE TO DHCS State of California Department of (Department of Health Care Services)

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Completed 23 December 2021

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