Get Dhcs 6001 (10/13) - Drug Medi-cal Application - Dhcs Ca

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.

1. Press the ‘Get Form’ button to obtain the DHCS 6001 application. The form will be opened in the available online editor for filling out.
2. 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.
3. Still in Section I, include the program name, program telephone number, 10-digit National Provider Identifier (NPI), and the mailing address of the clinic.
4. 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.
5. In Section III, check the appropriate box for the type of legal entity and attach the required documentation based on your selection.
6. Proceed to Section IV and outline the sources of funding and income for clinic operations, such as fees, third-party payments, or state funding.
7. In Section V, select the type of application (original, adding satellite site, additional services, etc.) and provide the prior address if applicable.
8. Identify the service modalities in Section VI, noting both the current and requested treatment components for the clinic.
9. Attach a detailed drug protocol in Section VIII along with the application for each service modality requested.
10. 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.
11. 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.
12. 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.