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
DHCS 5140 (Rev.2/19)
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