The information requested on this form is required by the Department of Health Care Services (DHCS) for purposes of identifying providers who have completed training in conducting brief cognitive health assessments. The information requested on this form is mandatory in order to receive Medi-Cal reimbursement for qualified brief cognitive health assessments.

Failure to provide the mandatory information may result in not receiving Medi-Cal reimbursement for conducting qualified brief cognitive health assessments. DHCS has the right to collect this information pursuant to Welfare and Institutions Code, Section 14132.171; Welfare and Institutions Code, Sections 14043 - 14043.75; the California Code of Regulations, Title 22, Sections 51000 – 51451; and the Code of Federal Regulations, Title 42, Part 455. The information provided will be shared with the University of California, San Francisco (UCSF) and its subcontractors overseeing the Dementia Aware operations as well as managed care plans.

The information provided may also be shared with other state and federal agencies as required by law or by request pursuant to the California Public Records Act (Government Code section 7920.000 et seq). In most cases, the individual(s) to whom this information pertains has the right to access it.