STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY DMC CERTIFICATION APPLICATION Department of Health Care Services Provider Enrollment Division Sacramento, CA 95899-7412 DRUG MEDI-CAL APPLICATION.
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the DHCS 6001 (10/13) - Drug Medi-Cal Application - Dhcs Ca online
Completing the DHCS 6001 (10/13) - Drug Medi-Cal Application is a crucial step for substance abuse clinics seeking participation in the Drug Medi-Cal program. This guide provides clear and supportive instructions to help users fill out the application form effectively and accurately in an online format.
Follow the steps to complete the application form successfully.
- Press the ‘Get Form’ button to obtain the DHCS 6001 application. The form will be opened in the available online editor for filling out.
- In Section I, provide the legal entity name of the clinic or satellite site, the 4-digit Drug Medi-Cal provider number if assigned, and the clinic's street address including the suite or room number.
- Still in Section I, include the program name, program telephone number, 10-digit National Provider Identifier (NPI), and the mailing address of the clinic.
- Complete Section II with the details of both the clinical director and the executive director, including their names and telephone numbers as well as their email addresses.
- In Section III, check the appropriate box for the type of legal entity and attach the required documentation based on your selection.
- Proceed to Section IV and outline the sources of funding and income for clinic operations, such as fees, third-party payments, or state funding.
- In Section V, select the type of application (original, adding satellite site, additional services, etc.) and provide the prior address if applicable.
- Identify the service modalities in Section VI, noting both the current and requested treatment components for the clinic.
- Attach a detailed drug protocol in Section VIII along with the application for each service modality requested.
- Follow through Sections IX to XIII by noting if the facility is a Federally Qualified Health Center, verifying residential licenses, and ensuring local zoning approvals are documented.
- In Section XIV, ensure the application is signed by the authorized individual, including their full legal name, title, and date of birth, and prepare to submit the completed application with all necessary documentation.
- Once all sections are filled out accurately, save your changes, print, or download the form for your records, and submit it to the DHCS as instructed.
Begin the application process online today and ensure your clinic is ready for Drug Medi-Cal program participation.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
Dec 9, 2019 — Drug Medi-Cal Certification ... The revised DMC application (DHCS 6001)...
Mar 30, 2020 — DENTAL ASSISTANT, MEDICAL ASSISTANT, MAGNETIC ... DRUG AND ALCOHOL ABUSE...
Get answers to your most pressing questions about US Legal Forms API.
What address do I use for Medi-Cal?
Here is more information on how to: Apply for Medi-Cal, get a Medi-Cal Application, or Find Out if you Qualify....Medi-Cal Contacts. GENERAL PUBLICPHONE / EMAILMedi-Cal Eligibility P.O. Box 997417, MS 4607 Sacramento, CA 95899-7417(916) 552-920014 more rows • Sep 2, 2022
How do I contact Medi-Cal California?
Medi-Cal Rx Members and Providers: If you have a question, need help, or need to report a problem, please call (800) 977-2273 for our Medi-Cal Rx Customer Service Center (CSC).
What is California Drug Medi-Cal waiver?
Medi-Cal waivers are programs that provide additional services to specific groups of individuals, limit services to specific geographic areas of the state, and provide medical coverage to individuals who may not otherwise be eligible under traditional Medicaid rules.
How does Medi-Cal work outside of California?
You will not get Medi-Cal if you move out of California. You may apply for Medicaid in the state you move to. If you are moving to a new county in California, you also need to tell the county you live in or the county you are moving to.
How do I change my address with California Medi-Cal?
To report changes, call Covered California at (800) 300-1506 or log in to your online account. You can also find a Licensed Insurance Agent, Certified Enrollment Counselor or county eligibility worker who can provide free assistance in your area.
Can I check my Medi-Cal status online?
Where Can I Access My Medi-Cal Member Services? You can access your member services online through your plan's website and the Covered California website. Each service manages different aspects of your coverage.
What is the drug Medi-Cal program?
Drug Medi-Cal is a treatment funding source for eligible Medi-Cal members. In order for Drug Medi-Cal to pay for covered services, eligible Medi-Cal members must receive substance use disorder (SUD) services at a Drug Medi-Cal certified program.
Is Medi-Cal only for California residents?
Medi-Cal is available to California residents who are U.S. citizens, permanent residents, legal aliens or U.S. nationals. There are several ways to qualify for the program. Some individuals qualify based on their household income level.
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.