Get Dhcs 5999

Filling out the Dhcs 5999 form is a crucial step in requesting an extension for your license or certification with the Department of Health Care Services in California. This guide will provide clear and supportive instructions to help you navigate the form efficiently and effectively.

Follow the steps to complete the form successfully.

1. Click the ‘Get Form’ button to obtain the Dhcs 5999 form. This will allow you to open the form in an accessible editor.
2. Fill in your provider number (license/certification number) in the designated field. This number is essential for identifying your application and must be accurate.
3. Input your legal name, mailing address, city, state, and zip code in the respective fields. Ensure that all information is up-to-date and correctly formatted.
4. Provide the facility name and address details, along with the associated city, state, zip code, phone number, website, fax number, and email address. Include complete and precise information.
5. Designate a contact person for the application along with their phone number and email address. This person will be the point of communication for any inquiries.
6. Fill in the director’s name, phone number, and email. This information is important for authorization and communication purposes.
7. Select the type of organization by checking the appropriate box: profit corporation, nonprofit corporation, sole proprietor, partnership, or government entity.
8. Indicate the target population served and the types of services provided by checking all relevant boxes. This may include residential certifications or various treatment options.
9. Complete the additional items required section by confirming that you have attached the necessary documentation, such as DHCS 5050, fire clearance, DHCS 5086, and a line item budget.
10. For residential facilities, indicate the treatment/recovery capacity and total building capacity along with the date of the current fire clearance.
11. Review the certifying statements thoroughly. Make sure to understand and verify that all information is accurate. Then, sign the application in blue ink.
12. Finally, send this completed form, along with any additional required items, to the address provided on the form. Ensure it is submitted before the expiration date to avoid delays.

Start filling out your Dhcs 5999 form online today to ensure a timely request for your license or certification extension.