Get Dhcs 5999

The Dhcs 5999 form is essential for requesting a license or certification extension within the State of California's health care system. This guide provides a detailed and user-friendly approach to help you fill out the form accurately and efficiently.

Follow the steps to complete the Dhcs 5999 form online.

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. Begin by filling out the provider number, which is your unique license or certification number.
3. Enter the legal entity name and mailing address, ensuring accuracy in the city, state, and zip code fields.
4. Provide contact information, including phone number, facility name, facility address, website, fax, and email for communication.
5. Identify the contact person and the director's name along with their corresponding phone numbers and emails.
6. Indicate the type of organization by selecting one of the options such as profit corporation, nonprofit corporation, sole proprietor, partnership, or government entity.
7. Specify the target population and select the types of services provided by marking the relevant checkboxes, including options for residential and outpatient services.
8. Complete the additional items section by providing the required documents, including staffing data, fire clearance, weekly activities schedule, and a line item budget.
9. For residential facilities only, include treatment/recovery capacity and total building capacity along with the date of the current fire clearance.
10. Review all entries for completeness to avoid unprocessed applications; ensure all required fields are filled.
11. Sign and print the application, using blue ink, and gather any additional signatures if necessary.
12. Submit the completed form along with required fees and attachments to the specified address for DHCS.

Start filling out your Dhcs 5999 form online today to ensure your license or certification remains active.